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Claims Risk Analyst

2 weeks ago

Cape Town, South Africa Momentum Metropolitan Holdings 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.

Momentum Health Solutions, an entity of Momentum Metropolitan Holdings Limited 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.
Role Purpose

An opportunity exists for a dynamic, focused individual to be part of the forensic investigations team in the Health Investigations Unit (HIU) in the Corporate team, to perform complex investigations into allegations of fraud, waste and abuse within the medical aid industry.
Requirements
- Tertiary qualifications in either law, compliance, accounting or forensic auditing.
- At least 3 years forensic or investigative experience.
- Ability to analyse and interpret large amounts of complex data.
- Able to work remotely and do so productively with strong time-management skills.
- Exceptional and proven organising and co-ordinating skills.
- Knowledge of the medical industry/medical schemes will be advantageous.
- Familiarity with Oracle systems will be advantageous.
Duties & Responsibilities
- Using data analysis techniques to detect potential fraud, waste and abuse.
- Performing investigations into allegations of fraud, waste and abuse and engage scheme members, healthcare service providers and other third parties.
- Using data visualisation software to enhance investigations.
- Continuous development of your own professional knowledge of the medical schemes’ environment and forensics discipline.
- Compiling comprehensive case reports.
- Liaising with societies, regulators and clinical specialists.
- Reporting cases to the relevant Regulatory Bodies and or to SAPS.
- Testifying at the Regulatory Body inquiries and or in criminal/civil proceedings if required. (Please note this may require interprovincial travel).
- Providing support to the management team to ensure that client SLA’s are adhered to.
- Communicating with respective service provider network companies.
- Co-ordinating and implementing approved sanctions.
- Contributing to a culture of teamwork and innovative thinking.
Competencies
- Proficient in MS Office (particularly Excel and Word).
- Excellent written and verbal communication skills.
- Strong report writing skills.
- Attention to detail.
- Leadership and peer mentorship ability.
- Strong personal integrity.
- Able to work well under pressure.
- Adaptability and quick learner.
- Strong work ethic.
- Passion for health investigations.
- Commitment to the collective success of the unit.
- Client
- centric approach.
- Self-motivated and driven.

Policy

We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.