Investigations Manager

2 days ago

Johannesburg, South Africa Dalitso Holdings Full time

Identify fraud trends and continuously develop process improvements and mitigation controls to support the Group Business. Proactively engage with key stakeholders both internally and externally to gather intelligence and create and develop relationships with key organisations.

**Responsibilities of the Role**:

- Successfully lead a team of Investigation Officers by providing quality regulatory technical expertise, case direction and excellent operational management to ensure assurance procedures, file and document reviews etc.
- Maintains an overview of all cases within the team to provide expert technical guidance and case direction and ensure the work is always of high quality and that there is a consistent, timely approach taken with each case.
- Responsible and accountable for high-quality and timely case progression within the team.
- Provides regular case updates/reviews to senior managers and key stakeholders, especially in relation to high profile and sensitive matters.
- Positively and proactively contributes as part of the Investigation leadership team in implementing changes and improvements as appropriate.
- Ensure that reports and documentation are produced to the highest standards, which will stand up to the scrutiny of the Section 91 Tribunal and Courts - supporting and coaching Investigation Officers as required.
- Effectively manage and motivates the team/individuals by providing clear communication, robustly managing performance/providing timely constructive feedback (regular reviews) and supporting/coaching individuals to improve and fully engage in their own development and learning.
- Work collaboratively across the organization and demonstrate a positive and proactive approach to achieving organisational objectives, including providing expertise and taking responsibility for leading on projects and priorities.
- Investigations are outcomes-focussed, timely and a risk-based approach is developed and executed for each investigation
- Interpret policy and decisions to stakeholders for effective communication
- Represent the company at various forums and interact with other stakeholders
- Identify and report falsified claims to the Legal Operations for recovery purposes
- Identify fraud trends by analysing data and industry alerts
- Identify suspicious activity and work with appropriate teams to investigate and thwart the activity
- Provide statistical data on losses on a regular basis
- Develop processes and procedures to prevent or minimise claims fraud losses
- Ensure Service Level Agreement and turnaround times of external service
- providers and internal investigators are adhered to Identify key risk indicators and establish mitigating controls
- Ensure that expenditure is incurred within the limits of the sanctioned budget
- Ensure that new risks are identified, reported to risk for monitoring and that mitigating controls are implemented
- Manage costs associated with investigation assignments
- Set staff performance targets and expectations, ensuring that the targets and expectations are achieved through regular monitoring and management
- Identify training requirements for staff, through effective staff management and assist them in meeting their training requirements
- Ensure ongoing transfer of specialised skills and multiskilling of the team aligned to the growth of the business.
- Responsible for ongoing development and support of your team, including identifying training needs, developing and deliverer of training to the team on relevant topics to support high quality and timely case progression.
- Compile monthly reports, as well as ad hoc reports, that meet regulatory reporting requirements requested by stakeholders (internal and external)
- Use appropriate templates and channels to report progress on a weekly and monthly basis
- Adhere to deadlines and timeously submit various periodical reports to Claims Management and internal committees
- Ensure accuracy and high quality of reports submitted to Claims and Medical Management, Group Risk and Compliance and internal committees
- Proactively report on key insights and use these to identify opportunities for continuous improvement and innovation
- Produce weekly, monthly, and quarterly complaints performance reports, update complaints KPI’s and provide reports for senior management

**Minimum Requirements**:

- NQF Level 7: Bachelor’s degree in Forensic Science or equivalent
- Certified Fraud Examiner
- Proven track record with a minimum of 12 years' investigations experience in the insurance industry
- Minimum 7 years in a managerial position (3 - 5 years of which should have been in fraud and forensic investigations)
- Computer literacy: Advanced MS Word, Excel and Outlook
- Good presentation skills and ability to interact with stakeholders at all levels
- Experience in medical fraud would be advantageous
- Managerial and Financial Management skills

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