Senior Claims Risk Specialist - Forensics at Momentum Metropolitan Holdings Limited

Role Purpose    

• This role involves conducting complex investigations into suspicious or fraudulent claims submitted to the medical scheme.
• Reviewing claim patterns to identify anomalies and irregularities.
• Analysing billing data and referral patterns to detect improper claims.
• Interviewing members and healthcare providers to collect evidence regarding questionable claims.
• Preparing detailed investigation reports, summarising findings and recommending corrective actions.

Requirements    

Qualifications 

• Matric or equivalent
• Bachelor’s degree in healthcare management, finance, accounting, auditing, forensics or a related field
• Advanced degree in Forensics, Compliance, Accounting, Investigations and Forensic Accounting, Commerce, Auditing or Forensic Auditing (Preferrable )
• Association of Certified Fraud Examiners (ACFE)
• Certification in fraud examination, healthcare compliance or a related field is desirable

Knowledge 

• Strong understanding of medical tariff codes, billing practices and reimbursement methodologies.
• Proven track record of conducting complex investigations and uncovering fraudulent activities.
• Excellent analytical skills with the ability to interpret and analyse large volumes of data.
• Proficiency in using desktop investigation tools, databases and software applications.
• Exceptional attention to detail and ability to maintain accuracy in a fast-paced and high-pressure environment.
• Excellent written and verbal communication skills, with the ability to effectively communicate findings and recommendations to diverse audiences.
• Ability to work independently with minimal supervision and manage multiple priorities effectively.

Experience 

• Minimum of 5 years of experience in healthcare claims processing, medical aid schemes administration or healthcare fraud investigations.

Duties & Responsibilities    

Internal Process 

• Conduct thorough desktop investigations into cases of suspected fraud, waste and abuse within healthcare claims.
• Analyse and review medical records, claims data, billing statements, and other relevant documentation to identify discrepancies, irregularities or potential fraudulent activities.
• Utilise knowledge of medical aid schemes, including their policies, scheme rules and procedures, to assess the validity of claims and identify potential fraudulent behaviour.
• Interpret and apply medical tariff codes and billing guidelines to evaluate the appropriateness and accuracy of billed services.
• Collaborate with internal stakeholders, including data analysts, clinical advisors and other investigators, to gather additional information and evidence for investigations.
• Prepare detailed investigation reports summarising findings, conclusions and recommendations for further action.
• Interview members, healthcare providers and other parties to collect evidence regarding questionable claims.
• Testify as an expert witness regarding investigation findings.

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.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
• Interview members, healthcare providers and other parties to collect evidence regarding questionable claims.
• Provide expert guidance and support to existing investigators on complex cases and assist in their professional development.

People

• The successful candidate should be able to address conflicts constructively, mediate disputes and foster a more collaborative and harmonious work environment.
• Strong communication skills are essential. The successful candidate should be able to communicate clearly and assertively, while also being respectful and professional.
• Lead by example through strong work ethic, integrity and respect towards all team members and all managers. Even though this role may not have direct managerial authority, strong leadership qualities are essential.
• Assist with team managment/investigation guidance when required.

Finance

• 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    

• An ability to analyse and interpret large amounts of complex data
• Medical aid claims knowledge
• Clinical knowledge
• Desktop forensic investigation knowledge
• Data analytics
• Forensic accounting
• Fraud Risk Management
• Medical billing knowledge
• Professionalism: Uphold the highest standards of ethics and integrity in decision-making and actions.
• Expertise: Demonstrate a high level of expertise in healthcare fraud, waste, and abuse investigation.
• Adaptability: Be flexible and willing to step into a limited leadership role when required.
• Teamwork and Leadership: Proven track record of uniting individuals constructively toward a common goal, embodying values of performance excellence and integrity, making it a true culture champion.

Closing Date    

• 2026/05/11