17 Oct
Health Solutions
Bellville
Job details
Here’s how the job details align with your profile.
Job type
- Permanent
Location
Bellville, Western Cape
Full job description
Introduction
Through our client-facing brands Metropolitan and Momentum, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.
Through our own network of advisers or via independent brokers and utilising new platforms Momentum Metropolitan provides practical financial solutions for people, communities, and businesses.
Disclaimer
As an applicant, please verify the legitimacy of this job advert on our company career page.
Role Purpose
The Senior Forensic Investigator will lead and conduct in-depth investigations into complex cases of fraud, waste, and abuse within the medical aid administration industry. This role bridges the technical expertise of a forensic investigator with strategic oversight and leadership, providing expert guidance on investigations, collaborating with stakeholders, and contributing to the development of investigation processes and projects. The ideal candidate will have a strong background in medical aid schemes and forensic investigations, with the ability to drive high-quality results and support the professional development of team members.
Requirements
Qualification
- Matric
- Bachelor’s degree in Healthcare Management, Finance, Accounting, Forensics, or a related field.
- Advanced degree or certification in fraud examination e.g., Certified Fraud Examiner ( Preferred)
Specific licensing or registration
- Certification in fraud examination (CFE), healthcare compliance or a related field (Desirable)
Knowledge
- Proven experience in healthcare compliance and fraud investigation, with expertise in healthcare fraud, waste, and abuse.
- Proven clinical expertise or knowledge.
- Strong analytical and research skills, with experience using various analytical tools to conduct desktop investigations.
- Excellent written and verbal communication skills.
- Exceptional attention to detail.
- Deep understanding of medical tariff codes, billing practices, and healthcare reimbursement methodologies.
Skills
- Advanced analytical skills with the ability to interpret and analyse large volumes of data.
- Strong report writing and presentation skills, with the ability to communicate findings effectively to diverse audiences.
- Excellent time management and organisational skills, with the ability to handle multiple priorities effectively.
- Ability to work in a fast paced and demand work environment.
Experience
- Minimum of 5 years of experience in healthcare fraud investigations, medical aid schemes administration, or related fields.
- Proven track record of managing and conducting complex investigations.
Duties & Responsibilities
Internal Process
- Lead Complex Investigations.
- Manage and conduct detailed desktop investigations into syndicate groups or complex cases of fraud, waste,
and abuse within healthcare claims.
- Analyse medical records, claims data, and billing statements to identify discrepancies, anomalies, and potentially fraudulent activities.
- Use your advanced knowledge of medical aid schemes, policies, and procedures to assess claim validity and detect fraud.
- Apply medical tariff codes and billing guidelines to ensure accuracy and appropriateness of billed services.
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.
- Collaborate with internal teams, including data analysts, clinical advisors, and other forensic investigators, to gather and validate evidence.
- Conduct interviews with members, healthcare providers, and other relevant parties to collect and corroborate evidence.
- Prepare comprehensive investigation reports to be presented to client summarising findings, conclusions, and recommendations for remedial actions.
- Ensure reports are clear, well drafted, accurate, and actionable for both internal stakeholders and external regulatory bodies.
- Testify as an expert witness in legal, regulatory, and disciplinary proceedings based on investigation findings.
- Willingness to travel (locally)
as needed for investigations, court appearances, and meetings. Travel is minimal to none however they may be a need if requested by client.
- Office-based investigation role with virtual engagements with members and providers (No field work involved and all analysis and investigations are performed strictly on a desktop level)
- Contribute to the development and enhancement of investigation processes, methodologies, and best practices.
- Provide expert guidance and support to existing investigators on complex cases and assist in their professional development.
People
- Address conflicts constructively, mediate disputes and foster a more collaborative and harmonious work environment.
- 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.
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
- Business Acumen
- Accountability and strong work ethic
- Client Commitment
- Drive for Results
- Leads Change and Innovation
- Collaborative mind-set
- Self-Awareness and Insight
- Diversity and Inclusiveness
- Problem Solving
- Resilience
- Emotional Intelligence
- Conflict Resolution
- Maintain strict confidentiality and ensure compliance with relevant laws, including the Medical Schemes Act and Protection of Personal Information Act.
▶️ Senior Forensic Investigator
🖊️ Health Solutions
📍 Bellville