Specialist: Forensic Investigations at PPS

Qualifications & Experience

• Matric
• Business related qualification (Forensics/Internal Audit/Commercial/IT).
• Medical Scheme Administration Experience, 1-2 years essential.
• Medical Aid Industry Billing and Coding practices
• Clinical and or Forensic background would be an advantage.
• Data Analytics exposure will be an advantage
• Ability to work cohesively in a team environment and balance multiple priorities.
• A team player who can work alone when required and without supervision.
• High level of attention to detail, resilience, enthusiasm, energy and drive.
• Positive, can-do attitude.
• Ethical and able to maintain confidentiality and manage boundaries.

Duties and Responsibilities    

KEY RESPONSIBILITIES INCLUDE:

• Investigating allegations of healthcare fraud against providers.
• Investigation of fraud cases received via Whistle-blowers and internally.
• Following up on leads regarding allegations of healthcare fraud.
• Using CAAT’s, identify claims that have been processed incorrectly.
• Conducting investigations into all aspects pertaining to healthcare fraud.
• Instituting measures to prevent fraud.
• Engaging perpetrator/s and taking necessary action where applicable.
• Analysing data to identify possible fraudulent trends i.e. coding, drugs analysis etc.
• Supply feedback to the Group Manager with regards to forensic audit findings.
• Perform internal audit as and when required.
• Liaise with scheme clients on the outcome of the investigation.

Additional tasks and responsibilities:

• Mend the RFMCF fraud line.
• Doing administrative tasks.
• Ad-hoc requests

KNOWLEDGE AND SKILLS

• Confident and professional manner.
• Articulate, both verbally and writing.
• Objective, logical and enquiring mind.
• Strong analytical and problem-solving skills.
• Good project management and team working ability
• Good time Management.
• Must be able to work independently and under pressure.