Manager: GEMS Claims Risk Management MMH250411-3

Role Purpose

The role incumbent will be responsible for managing and guiding a team focused on proactive risk identification, by bringing a systematic and structured approach to adjudicating financial risk to client schemes. Activities will be directed at preventing future losses due to Fraud, Waste, and Abuse (FWA) primarily in the prepayment domain, through interventions on specific practices but also through enhanced system controls. The role incumbent will also oversee the analytical review of the claims profiles of selected healthcare service providers, identify significant claims risk seen in anomalous claiming patterns, and make recommendations to the broader team on actions to mitigate this risk. Effective management of this team will ensure better outcomes for our clients.

Requirements

Qualifications and Experience

• Matric or equivalent qualification.
• Relevant B-degree in Accounting, Quantitative analysis, Risk Management, Auditing, Forensic Investigations, Criminal, or related field.
• A minimum of 5 years experience in either Risk Management, Audit, Compliance, or financial forensic services.
• Experience in managing people in cross-functional teams.
• Proven track record of delivering useful and relevant risk information to stakeholders in a format that effectively conveys the message.
• Experience in conducting desktop investigations and risk assessments, applying generally accepted forensic methodologies and practices.
• Experience in data analysis and/or data analytics (Essential).
• Experience in Financial Crime Compliance or in complex forensic investigations (Advantageous).
  
  

Knowledge

• Knowledge of Fraud, Waste, and Abuse regulatory environment.
• Knowledge of the Insurance, Health, and Financial Services Industry.
• Knowledge of Risk management standards and methodologies
  
  

Additional Requirements

• The successful candidate will be based in Bellville Office (Parc du Cap) and will be required to work from the office at least twice a week (Hybrid model).
• The successful candidate should be able and willing to travel between operations and/ or other destinations as and when required.
  
  

Duties and Responsibilities

Internal Process

• Develop an understanding of the Internal environment in line with business requirements.
• Perform prepayment analytics and other FWA analytical tools to identify outlier behaviour.
• Refine these prepayment tools to improve the sensitivity and accuracy thereof in detecting irregular claims behaviour.
• Review case reports or summaries prepared by direct reports to be presented to the client and management for timeous intervention in mitigating future financial losses to the client because of the detected fraud/abuse.
• Improving turnaround times of investigations with a focus on claims risk management within the healthcare business.
• Ensuring that policies, interventions, and sanctions are applied timeously and satisfy all appropriate regulatory requirements, Scheme Service Level Agreements (SLA's) and
• Standard Operating Procedures(SOP's), in relation to claims risk management.
• Audit the information received from providers and draw appropriate conclusions on the validity thereof and the extent to which the findings have been proven.
• Quantify the extent of losses incurred and contribute to the compilation of a report as required.
• Recommend necessary action to be taken, which could include closing a case and/or presenting findings to the client forum for decisioning or punitive sanctions where required.
• Attend client meetings or forums as well as healthcare service provider engagements as necessary, to address the risks at hand and to affect the necessary future action to be taken.
• Investigate client queries within the agreed service level and ensure that client receives timeous feedback.
• Manage documentation, records, investigation notes, and other evidence, ensuring accurate and accessible record keeping.
• 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.
• 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

• Manage & support a team of FWA Forensic Investigators.
• Mentor and provide guidance to the Investigator team to focus on investigations conducted and to improve their skill set and report writing.
• 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 Health 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.
  
  

Finances

• Implement and compile budgets to minimise expenditure in alignment with tactical delivery plans.
• Control the budget for area, including the authorisation of expenditures and implementation of financial regulations.
• Manage high risk and problematic financial issues in area of accountability and contribute to the development of policy.
• Plan and implement a cycle of medium term improvements to drive pricing of services and products.
• Implement and manage financial risk methodologies, techniques and systems and use to monitor and report on financial activities.
• Implement and provide feedback on the effectiveness of financial policy, practice and procedures: preventing illegal, unethical or improper conduct.
• Implement risk management, governance and compliance policies in own practice area, to identify and manage governance and risk exposure liability.
• Investigate reported willful acts of non-compliance to organisation policy and practice and report on findings.
  
  

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