Manager: Gems Claims Risk Management x2 at Momentum Metropolitan Holdings Limited

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    

Qualification

• Matric
• Relevant B-degree in Forensics, Risk Management, Auditing or Law
• Post-graduate qualification in related field (advantageous)
• Specific licensing or registration
• Certified Fraud Examiner (ACFE), or equivalent
• Membership to a professional body

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)

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.

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    

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.

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.

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.

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

Closing Date    

• 2026/06/12