Job Description

Closing Date 2024/03/01
Reference Number MMH240206-9
Job Title Claims Risk Analyst
Position Type Permanent
Role Family Risk
Cluster Health Solutions
Remote Opportunity Some of the time
Location - Country South Africa
Location - Province Western Cape
Location - Town / City Bellville
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.
Role Purpose

To conduct desktop based forensic investigations into potential instances of fraud, waste and or abuse across Momentum Health Solutions admisitered schemes and to collect documentory evidence, engage with all relevant parties i.e., service providers, members etc. drafting letters and investigation reports, perform data analytics and assit in the recovery of irregular paid claims.
Requirements

Qualification

• Valid Matric certificate.

A relevant tertiary qualification such as, Clinical/Healthcare related, Law, including Compliance, Business/Operations e.g., auditing, accounting & operations.

Knowledge

• Medical Scheme knowledge would be advantages.

Years of experience

• Three years of forensic experience.

Duties & Responsibilities

Internal Process

• Conducting desktop forensic investigation in order to identify potential instances of fraud, waste and or abuse across MHS administered schemes.

• Reporting on investigations conducted by submitting an investigation report to management for review and submission to the relevant scheme.

• Engage with relevant stakeholders (internal & external) to collect documentary evidence on instances of fraud, waste and or abuse identified.

• Draft letters providers/members to raise concerns with regards to irregularities identified

Perform data analytics to identify concerning trends on each investigation using the analytical tool available.

Client

• Build and maintain relationships with internal and external stakeholders.

• Deliver on service level agreements applicable to clients, internal and external stakeholders in order to ensure that client expectations are managed.

• Make recommendations to improve claims processes/controls where deficiencies in these areas are highlighted through investigations.

• 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 the assigned investigation to ensure that fraud waste and abuse risks are mitigated through identification and investigation of potential fraud waste and or abuse.

People

• Build strong relationships with peers and managers to ensure successful investigation outcomes.

• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialisation.

• Contribute to continuous innovation through the development, sharing and or implementation of new ideas and involvement of colleagues and staff.

• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.

• Take ownership for driving own career development.

Finance

• Assist in the recovery of irregular paid claims through engagement with providers and obtaining provider agreement on the repayment of irregular claims.

• Identify solutions to enhance cost effectiveness and increase operational efficiency.

Competencies

• Analytical thinking

• Healthcare industry knowledge (advantageous)

• Time management

• Attention to detail

• Problem-solving

• Communication

• Confidentiality

• Adherence to regulations

• Maturity: Display a high level of emotional maturity, professionalism, and soundjudgment in handling sensitive cases and maintaining confi dentiality as well asinterpersonal offi ce relationships.

• Hardworking: Demonstrate a strong work ethic, dedication, and a commitment tomeeting deadlines and delivering quality results.

• Professionalism: Uphold the highest standards of professionalism, ethics, andintegrity, with a focus on the job's core responsibilities rather than engaging indisruptive, insubordinate, or disrespectful practices.

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.

Momentum Metropolitan