Claims Risk Assessor

4 days ago


Bellville, South Africa Health Solutions Full time

**Introduction**
- Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members. Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.

**Disclaimer**
- As an applicant, please verify the legitimacy of this job advert on our company career page.

**Role Purpose**
- The Claims Risk Assessor is responsible for efficiently and effectively managing allegations related to fraud, waste, and abuse within the medical industry. This role involves receiving, analyzing, and investigating allegations, validating their credibility, and assessing the need for further action. The Assessor will also provide critical support in data retrieval for internal and external stakeholders. This position demands strong analytical and investigative skills, strict adherence to tight turnaround times, and a commitment to maintaining the quality of assessments and documentation. We are seeking individuals who are mature, hardworking, and are professional.

**Requirements**:
**Qualification**:

- Valid Matric Certificate
- Diploma or Higher Certificate in a relevant field (e.g., healthcare, law, compliance, forensics, audit, project management, investigations).

**Knowledge**:

- Previous experience in a similar role, particularly in healthcare compliance and fraud investigation.
- Strong analytical and research skills, with experience using analytical tools.
- Excellent written and verbal communication skills.
- Exceptional attention to detail and organizational abilities.
- Ability to work efficiently under pressure and meet strict deadlines.
- Understanding of healthcare regulations and fraud detection in the South African context.

**Duties & Responsibilities**

**Internal Process**:
Allegations Management
- Receive and document allegations related to fraud, waste, and abuse within the medical industry.
- Load allegations onto the case management system accurately and promptly.
- Ensure compliance with relevant healthcare and legal regulations.

Acknowledgment and Communication
- Send acknowledgment letters to complainants within 24 hours of receiving allegations.
- Notify relevant parties and request comments regarding the allegations.

Preliminary Investigation
- Utilize analytical tools to assess the validity of allegations.
- Review available evidence and information to make a preliminary determination.
- Determine whether a desktop investigation is needed.

Turnaround Time
- Complete the entire assessment process within a strict 7-day turnaround time.
- Manage workload and prioritize tasks to meet deadlines effectively.

Data Retrieval
- Search the case management system and relevant document repositories to provide internal and external stakeholders with requested data.
- Fulfill data requests within 5 days of receipt.

Volume Management
- Handle high volumes of allegations and data requests, adapting to fluctuations in workload.

Documentation
- Maintain detailed and accurate diary entries of all activities and assessments.
- Ensure all documentation meets high-quality standards and compliance requirements with the Administration Agreement, Client Standard Operating Procedure Documents and internal processes.

Compliance
- Adhere to all relevant healthcare, legal, and compliance policies and procedures.

**Client**:

- Build and maintain relationships with clients and internal and external stakeholders.
- Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed.
- Make recommendations to improve client service and fair treatment of clients within area of responsibility.
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
- Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
- Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
- Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

**People**:

- Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
- Positively influence and manage change and offer specialist support where required.
- Contrib


  • Claims Risk Assessor

    3 months ago


    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings,...

  • Claims Risk Assessor

    7 months ago


    Bellville, South Africa Health Solutions Full time

    **Introduction** Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings,...


  • Bellville, South Africa Sanlam Full time

    **THE ROLE** - This career opportunity is available at Non-Motor region and the successful incumbent will be based in Bellville**WHAT WILL YOU DO?**WHAT WILL MAKE YOU SUCCESSFUL IN THE ROLE?** - Receiving instruction from Claims Service Consultant (appraisal notes & docs). - Checking completion and correctness of document and policy conditions. - Planning...


  • Bellville, South Africa Santam Full time

    OPPORTUNITY Santam Direct Claims department has a position available for a Desktop Merit Motor Assessor who will be based in Tygervalley, Cape town. WHAT WILL YOU DO The desktop assessor is accountable for all motor claim interactions directly with the client. Processing of all direct merit claims administration including co-ordinating and overseeing all...


  • Bellville, South Africa Santam Full time

    OPPORTUNITY Santam’s Claims department has a position available for a Claims Service Consultant (Non-Motor) based in Bellville. WHAT WILL YOU DO The Claims Service Consultant (CSC) for Field Assessment claims is accountable for the claims end to end and is responsible for coordinating and overseeing all actions on claims in this processing channel WHAT...


  • Bellville, South Africa Sanlam Full time

    OPPORTUNITY- Santam’s Riscor Claims Department has positions available for a Claims Service Consultant based in Bellville, Western Cape.The purpose of this position is to get the allocated Motor/Non-Motor Claims ready for an assessor to be appointed, to handle all such claim enquiries and be responsible for the allocated claim until payment is complete....


  • Bellville, South Africa Sanlam Full time

    OPPORTUNITY- Santam’s Non-Motor Claims (Riscor Preferred Broker Claims Hub) department have a position available for a Non-Motor Desktop Assessor (JG09) who will be based in Bellville Cape Town.To assess merit and quantum of a non-motor damage claim through digital photographs, etc. This position entails assessing most types of non - motor claims. Further...

  • Claims Assessor

    15 hours ago


    Bellville, South Africa South African Government Department of Labour Full time

    Centre: Bellville (Western Cape) Requirements: Three-year tertiary qualification degree or diploma in Public Management/ Administration/ Social Science/ OHS/ Finance/ HRM is required. Three to five years’ experience in a claims processing environment of compensation or medical claims if highly desirable plus supervisory experience. Knowledge: Knowledge of...


  • Bellville, South Africa Santam Full time

    OPPORTUNITY This career opportunity is available at Santam's Direct Claims department for a Motor Claims Service Consultant, who will be based in Bellville, Cape Town. WHAT WILL YOU DO The purpose of this position is to get the allocated Motor Claims ready for an assessor to be appointed, to handle all such claim enquiries and be responsible for the...


  • Bellville, South Africa Sanlam Full time

    **THE ROLE** - This career opportunity is available at Non-Motor region and the successful incumbent will be based in Bellville**WHAT WILL YOU DO?**- WHAT WILL MAKE YOU SUCCESSFUL IN THE ROLE?- Receiving instruction from Claims Service Consultant (appraisal notes & docs). - Checking completion and correctness of document and policy conditions. - Planning...

  • Claims Risk Analyst

    9 months ago


    Bellville, South Africa Health Solutions Full time

    **Introduction** Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings,...


  • Bellville, South Africa Sanlam Full time

    OPPORTUNITY- To plan, deliver and evaluate Technical and Operational training to target audience. (Classroom, Practical or on the job training). The main focus of this role is to upskill Motor Assessors in various factors supporting all South Africa regions and Namibia, based in Bellville**KEY RESPONSIBILITIES** - Provide ongoing Technical and Operational...

  • Risk Analyst X2

    7 months ago


    Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings,...


  • Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings,...


  • Bellville, South Africa Health Solutions Full time

    **Introduction** - Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings,...

  • Motor Desktop Assessor

    7 months ago


    Bellville, South Africa Sanlam Full time

    CAREER OPPORTUNITY- A position has become available for a Motor Desktop Assessor and will be based in the Motor Claims department at the Cape Town or ParktownThe purpose of this position is to determine the quantum and merit of segmented motor claims by performing investigations, verifying the description of the event with the loss, negotiating with (client,...


  • Bellville, South Africa Edge Personnel (Pty) Ltd Full time

    You will be responsible to ensure that benefit claims are processed and paid accurately and in accordance with the defined timing standards. Processing benefit claims Document collation Document distribution Document filing Basic capturing/ updating on the administration system: Capturing of Nomination Forms Static date in regards of new claims Static...


  • Bellville, South Africa Sanlam Full time

    **Who are we?** The Sanlam Retail Affluent business (SRA) is dedicated to empower South Africans in the middle - and upper-income segments to be financially confident, secure and prosperous. With deep client understanding and a focus on excellence in technology, client and intermediary experiences, SRA delivers financial solutions including comprehensive...


  • Bellville, South Africa Sanlam Full time

    About Sanlam Corporate Sanlam Corporate forms part of Sanlam Life and Savings Cluster which offers retail and corporate life insurance, health and investment products in South Africa. Our vision is to be the preferred partner to Corporate and Public Sector by providing an awesome client experience and comprehensive solutions that enable the financial...


  • Bellville, South Africa Hr Legend Full time

    Join our client in the logistics sphere as their Legal and Risk manager. It is imperative that youve worked with marine/shipping insurance claims. If not, no need to apply. We are not sourcing an attorney or advocate with years of experience but rather someone who has worked for a corporate company in their legal department and insurance / claims had to form...