Manager: Gems Claims Risk Management

**Introduction**

**Role Purpose**

The role incumbent will be responsible for managing and guiding a team focused on proactive risk identification, by bringing a systematic and structured approach to adjudicating financial risk to client schemes. Activities will be directed at preventing future losses due to Fraud, Waste, and Abuse (FWA) primarily in the prepayment domain, through interventions on specific practices but also through enhanced system controls. The role incumbent will also oversee the analytical review of the claims profiles of selected healthcare service providers, identify significant claims risk seen in anomalous claiming patterns, and make recommendations to the broader team on actions to mitigate this risk. Effective management of this team will ensure better outcomes for our clients.

**Requirements**:
**Qualifications and Experience**
- Matric or equivalent qualification.
- Relevant B-degree in Accounting, Quantitative analysis, Risk Management, Auditing, Forensic Investigations, Criminal, or related field.
- A minimum of 5 years experience in either Risk Management, Audit, Compliance, or financial forensic services.
- Experience in managing people in cross-functional teams.
- Proven track record of delivering useful and relevant risk information to stakeholders in a format that effectively conveys the message.
- Experience in data analysis and/or data analytics (Essential).
- Experience in Financial Crime Compliance or in complex forensic investigations (Advantageous).

**Knowledge**
- Knowledge of Fraud, Waste, and Abuse regulatory environment.
- Knowledge of the Insurance, Health, and Financial Services Industry.
- Knowledge of Risk management standards and methodologies

**Additional Requirements**

**Duties & Responsibilities**
- Develop an understanding of the Internal environment in line with business requirements.
- Perform prepayment analytics and other FWA analytical tools to identify outlier behaviour.
- Refine these prepayment tools to improve the sensitivity and accuracy thereof in detecting irregular claims behaviour.
- Review case reports or summaries prepared by direct reports to be presented to the client and management for timeous intervention in mitigating future financial losses to the client because of the detected fraud/abuse.
- Manage & support a team of FWA Forensic Investigators.
- Mentor and provide guidance to the Investigator team to focus on investigations conducted and to improve their skill set and report writing.
- Improving turnaround times of investigations with a focus on claims risk management within the healthcare business.
- Ensuring that policies, interventions, and sanctions are applied timeously and satisfy all appropriate regulatory requirements, Scheme Service Level Aagreements (SLA's) and Standard Operating Procedures(SOP's), in relation to claims risk management.
- Audit the information received from providers and draw appropriate conclusions on the validity thereof and the extent to which the findings have been proven.
- Quantify the extent of losses incurred and contribute to the compilation of a report as required.
- Recommend necessary action to be taken, which could include closing a case and/or presenting findings to the client forum for decisioning or punitive sanctions where required.
- Attend client meetings or forums as well as healthcare service provider engagements as necessary, to address the risks at hand and to affect the necessary future action to be taken.
- Investigate client queries within the agreed service level and ensure that client receives timeous feedback.
- Manage documentation, records, investigation notes, and other evidence, ensuring accurate and accessible record keeping.
- Participate in legal processes where required and testify to investigation findings if necessary.
- Liaise with various internal and external stakeholders to build and maintain relationships.
- Keep abreast of relevant legislation, regulation, and policies within the Healthcare industry.
- Contribute to the development of fraud prevention policies, strategies, plans, and other related documents.
- Managing a high-performance team.
- Contribute to creating a positive work climate and culture toenergise employees, give meaning to work, minimise workdisruption and maximise employee productivity.
- Contribute to and drive a culture that guides and directs bestpractice, fostering an environment of continuous learning, peoplegrowth and improvement and cohesiveness.
- Be innovative and encourage innovation, change agility andcollaboration within the team.

**Competencies**
- Advanced written communication and excellent report-writing skills.
- Proficient with Microsoft Office 365 (MS Word, One Drive, MS Excel (at an advanced level of proficiency), MS PowerPoint, MS Outlook, etc.)
- Highly developed interpersonal skills.
- Good composure.
- Meticulous attention to detail.
- Problem-solving.
- Curiosity.
- Strong data analytics (Essential).
- Leaders