Job Description

:A global health and life insurance organisation is looking for a highly skilled professional with claims auditing experience, strong clinical expertise, and exceptional attention to detail. This is an opportunity to join a highly professional team on a hybrid, 6-month fixed-term contract.You will be responsible for conducting detailed pre-payment claim audits to identify suspicious claims, ensure accuracy, and mitigate fraud risks before payment is processed. This role is a proactive safeguard against fraudulent or invalid claims, reducing financial exposure to the organisation. The successful candidate must possess strong clinical expertise to assess medical claims effectively and validate treatments before payment approval.KEY ROLEPre-payment Claims Auditing & Validation:Conduct regular audits of processed claims to identify discrepancies, fraud, and errors.Manage a list of suspicious claimants and conduct detailed audits before payment is approved.Perform sample audits on other claims to detect anomalies and ensure compliance with policy terms.Call medical service providers to verify treatments, procedures, and hospitalisation claims before payment.Validate claims against medical records, test results, and utilization histories.Ensure claims decisions align with policy conditions, ethical standards, and regulatory requirements.Maintain detailed records of audit processes, decisions, and outcomes.RESPONSIBILITIES:Fraud Prevention & Risk Assessment:Identify potential fraudulent claims, abuse, and overbilling before payments are made.Escalate high-risk claims to the risk and legal departments for further investigation.Stay updated on industry fraud trends and emerging risk mitigation practices.Stakeholder Collaboration & Communication:Collaborate with claims teams, risk management, and legal departments.Clearly communicate audit findings and recommendations to senior management.Address inquiries from policyholders regarding audit decisions.Ensure strict compliance with internal policies and industry regulations.RequirementsMedical or clinical background (Nursing, Medicine, or Healthcare Claims Auditing preferred)
Completed formal qualification: Ideally a Bachelors degree in Nursing, Medicine, Insurance, or a related field
Minimum 3 - 5 years of experience in medical claims auditing, fraud detection, or risk management
Experience in pre-payment claims validation is highly advantageous
Proficiency in claims management systems and investigative tools
Organised
Excellent attention to detail
Proven track record of quality communication ability
Good email communication skills
Respect for timelines and experience with deadline management
Self-motivatedClinical Expertise: Strong understanding of medical terminology, conditions, and treatments
Critical Thinking: Ability to assess medical and financial documents to detect inconsistencies.
Regulatory Compliance: Knowledge of insurance policies and industry fraud detection strategies.Benefits

• Opportunity to work in a great business with a dynamic team committed to risk management and operational efficiency

• Hybrid working arrangement for JHB based candidate

• Fixed term contract with a focus on specialised expertise

• Key role in fraud prevention with a direct impact on company financials.

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