Talent Pool: Claims Risk Manager

Role Purpose

To lead a team in proactively identifying and mitigating financial risks, preventing losses from Fraud, Waste, and Abuse (FWA), and ensuring the integrity of claims processing for client schemes.

Requirements

• Matric as a minimum
• Bachelor degree or equivalent qualification in a relevant field such as Accounting, Quantitative Analysis, Risk Management, Auditing, Forensic Investigations, Criminal Justice, or related discipline - (Essential).
• Professional certifications in Risk Management, such as Certified Risk Manager (CRM), Certified in Risk and Information Systems Control (CRISC), or similar certifications - (Desirable).
• 5 - 8 years of experience in risk management, audit, compliance, financial forensic services, or a related field.
• 2 - 3 management/leadership experience
• Experience in financial crime compliance or involvement in complex forensic investigations - (Desirable).
• Understanding of claims processes, procedures, and best practices.
• Knowledge of Fraud, Waste, and Abuse (FWA) regulatory environment, FWA detection techniques, investigative methodologies, and prevention strategies.
• Knowledge of risk management standards and methodologies.
• Understanding of the industry-specific regulations, policies, and practices.
• Knowledge of applicable laws, regulations, and compliance requirements.
• Understanding of investigative methods, evidence collection, and report writing in a forensic investigation context.
• Awareness of ethical standards, integrity principles, and adherence to compliance frameworks.

Duties and Responsibilities

INTERNAL PROCESS

• Develop a comprehensive understanding of the internal environment in line with business requirements to inform decision-making and strategy.
• Perform prepayment analytics and utilise other Fraud, Waste, and Abuse (FWA) analytical tools to identify outlier behaviour, enabling early detection of irregular claims.
• Refine prepayment tools to enhance sensitivity and accuracy in detecting irregular claims behaviour, improving the effectiveness of fraud prevention measures.
• Review case reports or summaries prepared by direct reports for timely intervention, mitigating future financial losses due to detected fraud/abuse and ensuring client protection.
• Manage and support a team of Fraud, Waste, and Abuse (FWA) Forensic Investigators, fostering collaboration and maximising their performance.
• Improve turnaround times of investigations, emphasising claims risk management within the business, optimising efficiency and minimising potential losses.
• Ensure timely application of policies, interventions, and sanctions, meeting regulatory requirements, Scheme Service Level Agreements (SLAs), and Standard Operating Procedures (SOPs) in claims risk management, ensuring compliance and effective risk mitigation.
• Audit information received from providers, draw appropriate conclusions on validity, and establish the extent to which findings are proven, ensuring accurate and reliable assessment of claims.
• Quantify incurred losses and contribute to the compilation of a comprehensive report, providing insights on financial impact and risk exposure.
• Recommend necessary actions, including case closure or presenting findings to the client forum for decision-making or implementing punitive sanctions when required, enabling appropriate measures to be taken against fraudulent activities.
• Manage documentation, records, investigation notes, and other evidence to maintain accurate and accessible records, supporting investigations and regulatory requirements.
• Participate in legal processes where necessary and testify to investigation findings if required, providing expert insights in legal proceedings.
• Stay updated on relevant legislation, regulations, and policies within the finance/insurance industry, ensuring compliance and adaptability to changing requirements.
• Contribute to the development of fraud prevention policies, strategies, plans, and related documents, enhancing the organisation's ability to detect and prevent fraud.

CLIENT

• Attend client meetings or forums, engaging with providers to address risks and foster proactive risk management and collaboration.
• Investigate client queries within agreed service levels, providing timely feedback, resolving concerns, and maintaining client satisfaction.
• Liaise with internal and external stakeholders, establishing and maintaining relationships to facilitate effective communication and cooperation.
• Deliver on service level agreements, meeting agreed-upon service standards and managing client expectations.
• Make recommendations to enhance client service, ensuring fair treatment and improving overall client satisfaction.
• Continuously monitor turnaround times and quality standards, resolving issues promptly to enhance service delivery.
• Manage client query processes, tracking and accurately resolving queries to improve client service and business processes, ensuring timely and satisfactory resolution of client concerns.

PEOPLE

• Foster a positive work climate and culture, promoting employee engagement, minimising disruptions, and maximising productivity, creating a supportive and motivated team environment.

FINANCE

• Contribute to the development of area-specific budgets, minimising expenditure in alignment with operational plans, optimising financial resources.
• Identify solutions to enhance cost-effectiveness and increase operational efficiency, driving financial optimisation.
• Implement and provide input into governance processes, systems, and legislation within the area of specialisation, ensuring compliance and risk management.
• Escalate unresolved policy and governance compliance issues via appropriate channels for investigation and resolution, ensuring adherence to policies and regulations.
• Provide input into the development of risk identification processes and communicate recommendations in the appropriate forum, improving risk assessment and mitigation strategies.

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