Claims Risk Assessor at Momentum Metropolitan Holdings Limited

Requirements

Qualification

• Valid Matric Certificate
• Diploma or Higher Certificate in a relevant field (e.g., healthcare, law, compliance, forensics, audit, project management, investigations).

Internal Process

Allegations Management

• Receive and document allegations related to fraud, waste, and abuse within the medical industry.
• Load allegations onto the case management system accurately and promptly.
• Ensure compliance with relevant healthcare and legal regulations.

Acknowledgment and Communication

• Send acknowledgment letters to complainants within 24 hours of receiving allegations.
• Notify relevant parties and request comments regarding the allegations.

Preliminary Investigation

• Utilize analytical tools to assess the validity of allegations.
• Review available evidence and information to make a preliminary determination.
• Determine whether a desktop investigation is needed.

Turnaround Time

• Complete the entire assessment process within a strict 7-day turnaround time.
• Manage workload and prioritize tasks to meet deadlines effectively.

Data Retrieval

• Search the case management system and relevant document repositories to provide internal and external stakeholders with requested data.
• Fulfill data requests within 5 days of receipt.

Volume Management

• Handle high volumes of allegations and data requests, adapting to fluctuations in workload.

Documentation

• Maintain detailed and accurate diary entries of all activities and assessments.
• Ensure all documentation meets high-quality standards and compliance requirements with the Administration Agreement, Client Standard Operating Procedure Documents and internal processes.

Compliance

• Adhere to all relevant healthcare, legal, and compliance policies and procedures.

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.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

People

• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and 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 career development.

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.