Claims Risk Analyst at Momentum Metropolitan Holdings Limited

Role Purpose    

• To conduct desktop based forensic investigations into potential instances of fraud, waste and or abuse across Momentum Health administered schemes and to collect documentary evidence, engage with all relevant parties i.e., service providers, members etc. drafting letters and investigation reports, perform data analytics and assist 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 MH 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 sound judgment in handling sensitive cases and maintaining confidentiality as well as interpersonal office relationships.
• Hardworking: Demonstrate a strong work ethic, dedication, and a commitment to meeting deadlines and delivering quality results.
• Professionalism: Uphold the highest standards of professionalism, ethics, and integrity, with a focus on the job's core responsibilities rather than engaging indisruptive, insubordinate, or disrespectful practices.

Closing Date    

• 2026/06/19