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
Bachelor degree or equivalent qualification in a relevant field such as healthcare management, healthcare administration, risk management, or a related discipline (Essential)
Certified Fraud Examiner (CFE) with the Association of Certified Fraud Examiners (ACFE) (Desirable)
5 – 8 years’ experience in risk management/audit/compliance/financial forensic and or relevant equivalent experience
2 – 3 years management/leadership experience
Demonstrated experience in the healthcare/ insurance industry or related industry
Knowledge of relevant regulations, laws, and compliance requirements related to healthcare claims and risk management
Knowledge of risk management principles and practices, including identification, assessment, mitigation, and monitoring of risks associated with healthcare claims
Familiarity with fraud detection techniques, patterns, and prevention strategies specific to the healthcare industry, including knowledge of common fraudulent activities and risk related indicators
Knowledge of case management principles and methodologies
Familiarity with medical terminology, coding systems, and healthcare service provider practices
Duties & Responsibilities
PROCESS
Efficiently ensure the accuracy, quality, and overall improvement of case reports produced by claims risk analysts, strengthening quality assurance and oversight in the process.
Drive improvements in investigation turnaround times, with a specific emphasis on expediting claims risk management within the respective business areas.
Ensure the prompt and compliant application of policies, interventions, and sanctions, in alignment with regulatory requirements, service level agreements (SLAs), and standard operating procedures (SOPs) for effective claims risk management.
Provide comprehensive support and ensure the investigations unit promptly and effectively responds to requests and queries, ensuring efficient resolution and proactive assistance.
Execute all tasks and responsibilities with unwavering commitment to upholding the highest ethical and professional standards.
CLIENT
Thoroughly review written correspondence addressed to healthcare service providers to ensure factual accuracy and identify and rectify any grammatical errors.
Engage in client engagements and diligently provide comprehensive reports on investigation outcomes to foster collaboration, transparency, and informed decision-making for clients.
Thoroughly compile and meticulously review client and productivity reports to ensure accuracy, identify trends, and derive valuable insights for informed decision-making and process improvement.
Actively attend and deliver impactful presentations at industry bodies and regulatory engagements to share expertise, contribute valuable insights, and foster collaboration and knowledge exchange within the industry.
Participate in Health Profession Council of South Africa (HPCSA) hearings and effectively present compelling evidence on referred complaints when necessary, ensuring a fair and thorough adjudication process.
Provide compelling and credible evidence in court, when required, pertaining to investigation processes, ensuring the accurate representation of findings and supporting the legal proceedings.
PEOPLE
Effectively lead and oversee the team responsible for analysing and identifying instances of Fraud, Waste, and Abuse (FWA) in medical claims submitted to schemes, ensuring thorough investigation, prompt action, and protection of the integrity of the claims process.
Conduct effective performance management of underperforming employees in accordance with the company’s human capital policies, aiming to enhance individual performance, foster growth, and maintain a high standard of productivity within the team.
Take a leadership role in guiding and developing direct reports, ensuring their expertise and proficiency in conducting thorough and effective investigations related to Fraud, Waste, and Abuse (FWA), thereby contributing to the overall integrity and success of the investigative process.
Champion a culture of performance excellence by providing support, guidance, and resources that empower individuals and teams to consistently achieve high levels of performance and exceed expectations.
Actively contribute to fostering a positive work climate and culture that energises employees, instills a sense of purpose in their work, minimises disruptions, and maximises overall productivity, resulting in a highly engaged and motivated workforce.
Actively contribute to and lead the development of a culture that promotes and embraces best practices, fosters continuous learning, encourages personal and professional growth, drives improvement initiatives, and cultivates a sense of cohesion and collaboration among team members.
Efficiently manage team performance to ensure the attainment of business objectives by setting clear expectations, providing constructive feedback, offering necessary support, and fostering a culture of accountability and achievement.
Promote and inspire innovation by fostering a culture of creativity, embracing change agility, and encouraging collaboration within the team, leading to continuous improvement and impactful solutions.
FINANCE
Proactively identify and analyse solutions to optimise cost-effectiveness and enhance operational efficiency, leveraging innovative approaches and industry best practices to drive improvements in resource utilisation and overall organisational performance.
Demonstrate responsible stewardship by effectively managing financial and other company resources under your purview, ensuring their proper allocation, utilisation, and safeguarding while adhering to established policies and practices.
Competencies
Communication skills (written and verbal)
Problem solving skills
Operational risk management skills
Organisational awareness skills
Customer engagement skills
Critical thinking skills
Closing Date
2026/04/27
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