Specialist: Forensic Investigations

5 months ago


Centurion, South Africa PPS Recruitment Full time

**Job Advert Summary**:
Applications are invited for the above-mentioned position, to be filled as soon as possible.

**Minimum Requirements**:
**Qualifications & Experience**
- Matric
- Business related qualification (Forensics/Internal Audit/Commercial/IT).
- Medical Scheme Administration Experience, 1-2 years essential.
- Medical Aid Industry Billing and Coding practices
- Clinical and or Forensic background would be an advantage.
- Data Analytics exposure will be an advantage
- Ability to work cohesively in a team environment and balance multiple priorities.
- A team player who can work alone when required and without supervision.
- High level of attention to detail, resilience, enthusiasm, energy and drive.
- Positive, can-do attitude.
- Ethical and able to maintain confidentiality and manage boundaries.

**Duties and Responsibilities**:
**KEY RESPONSIBILITIES INCLUDE**:

- Investigating allegations of healthcare fraud against providers.
- Investigation of fraud cases received via Whistle-blowers and internally.
- Following up on leads regarding allegations of healthcare fraud.
- Using CAAT’s, identify claims that have been processed incorrectly.
- Conducting investigations into all aspects pertaining to healthcare fraud.
- Instituting measures to prevent fraud.
- Engaging perpetrator/s and taking necessary action where applicable.
- Analysing data to identify possible fraudulent trends i.e. coding, drugs analysis etc.
- Supply feedback to the Group Manager with regards to forensic audit findings.
- Perform internal audit as and when required.
- Liaise with scheme clients on the outcome of the investigation.

**Additional tasks and responsibilities**:

- Mend the RFMCF fraud line.
- Doing administrative tasks.
- Ad-hoc requests

**KNOWLEDGE AND SKILLS**
- Confident and professional manner.
- Articulate, both verbally and writing.
- Objective, logical and enquiring mind.
- Strong analytical and problem-solving skills.
- Good project management and team working ability
- Good time Management.
- Must be able to work independently and under pressure.



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