Claims Risk Analyst
3 days ago
**Introduction**
- Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities.
**Disclaimer**
- As an applicant, please verify the legitimacy of this job advert on our company career page.
**Role Purpose**
**Requirements**:
- Matric
- Relevant degree / diploma in Forensics or Accounting is advantageous
- 3 years’ experience in forensics or investigating experience is essential
- Drivers License is essential
- Willingness to travel on behalf of the office when required is essential
- In-depth knowledge/ understanding of various claims methods is essential
- Knowledge of Forensic Investigations is essential
- Ability to compile clinical forensic reports for clients is essential
- Knowledge of the regulatory legislation of the Health Care industry is advantageous
- Knowledge of provider billing behaviour and patterns is advantageous
**Duties & Responsibilities**
- Investigating fraud cases allocated in terms of the required protocols
- Using data analysis techniques to detect potential fraud
- Using data visualization software to enhance investigations
- Compilation of comprehensive forensic case reports
- Liaising with relevant Societies and or Medical Advisors
- Reporting cases to relevant Regulatory Bodies and / or SAPS
- Assisting with Claims specific projects
- Committing to developing knowledge
- Pre-analytics and maintenance of outliers
- Engagements providers /members
- Testing new rules requirements FWA (error codes and system testing)
**Competencies**
- An ability to analyse and interpret large amounts of complex data in Excel
- Strong time management skills
- Proven and exceptional organising and coordinating skills
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