Job Description

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.

Disclaimer

As an applicant, please verify the legitimacy of this job advert on our company career page.

Role Purpose

To oversee the claims risk management investigation process, review prepared case reports, and guide the medical claims investigation process to ensure it aligns and supports team objectives.

Requirements

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Qualification

Matric
Relevant B-degree in Forensics, Risk Management, Auditing or Law
Post-graduate qualification in related field (advantageous)
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Specific licensing or registration

Certified Fraud Examiner (ACFE), or equivalent
Membership to a professional body
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Knowledge

Knowledge of Fraud, Waste and Abuse within the healthcare regulatory environment (FWA)
Knowledge of Medical Aid Scheme fraud investigation methodologies
The ability to guide the development of quantitative models to assist with investigations and identification methodology (advantageous)
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Skills

Forensic Investigations
Excellent report writing skills
Interpretation of data
The ability to coherently communicate findings/ make recommendations based off information deduced from the data
Highly developed interpersonal skills
Meticulous attention to detail
Exceptional aptitude for handling multiple tasks simultaneously and systematically under stressful conditions.
Outstanding communication skills and ability to communicate at all levels throughout the organisation.
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Experience

At least 5 years' experience in the field of forensic/corporate investigations (essential)
5 years management experience (essential)
Healthcare services investigations
Experience in Financial Crime Compliance (advantageous)
Experience in complex forensic investigations

Duties & Responsibilities

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Internal Process

Perform allegation assessment using real time fraud detection analytical tools to identify any outlier behaviour and potential FWA in reported practices.
Review allegation reports and providing insights & feedback.
Decide whether to allocate or close a case based on the assessment conducted.
Mentor and provide guidance to the Assessment team to focus the assessment conducted and to improve their investigative skills.
Audit the information received from providers and draw appropriate conclusions.
Attend client meetings and governance forums as well as industry engagements as necessary.
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.
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Client

Build and maintain relationships with clients and internal and external stakeholders
Deliver on service level agreements applicable to clients and internal and external stakeholders in order to ensure that client expectations are managed
Make recommendations to improve client service and fair treatment of clients within area of responsibility
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.
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People

Create a positive work climate and culture to energise employees, give meaning to work, minimise work disruption and maximise employee productivity.
Demonstrate exemplary leadership behaviour, through personal involvement, commitment and dedication in support of organisational values.
Select and recruit suitably qualified talent in line with Employment Equity principles and Momentum Group values.
Drive a culture that guides and directs best practice, fostering an environment of continuous learning, improvement and cohesiveness.
Enable a learning and growth culture whereby information regarding successes, issues, trends and ideas are actively shared between team members.
Execute effective workforce planning practices to ensure that staffing requirements are accurately forecasted.
Identify employee growth and development needs and schedule interventions to enable ongoing development, training and personal growth.
Effectively manage performance within the team in order to ensure business objectives are achieved.
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Finance

Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
Identify solutions to enhance cost effectiveness and increase operational efficiency.
Implement and provide input into governance processes, systems and legislation within area of specialisation.
Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution purposes
Provide input into the risk identification processes development and communicate recommendations in the appropriate forum.

Competencies

Directing People
Adopting Practical Approaches
Making Decisions
Developing Strategies
Resolving Conflict
Empowering Individuals
Team Working
* Upholding Standards