Claims Risk Specialist MMH260911-10

Role Purpose

The purpose of this role is to lead and coordinate the recovery of Fraud,Waste, and Abuse (FWA) debt from healthcare service providers on behalf of the medical scheme. This includes managing debt acknowledgement processes,tracking and reconciling recoveries,engaging with legal stakeholders and producing executive-level reports and analyses.

The role ensures accurate financial recovery, supports compliance with regulatory requirements and contributes to the financial sustainability of the Scheme by safeguarding member benefits and enforcing accountability among service providers identifed as anomolous claimers.

Requirements

Qualifications

• Matric
• Bachelor’s degree in finance,accounting or auditing with financial auditing major or related field

Experience

• 3–5 years' relevant experience in a similar or closely related environment, including supervisory, team leadership, or management experience

Knowledge

• Strong analytical and reconciliation skills
• Proficiency in Excel (including pivottables, charts, data validation)
• Legal process awareness in healthcare and debt recovery
• Effective communication and presentation skills
• Project management and execution
• Attention to detail and data accuracy
• Lifestyle and forensic auditing skills(advantageous)
• Familiarity with the Medical Schemes Act, Scheme rules, and FWA frameworks
• Prior experience working with Medical Scheme administrators(advantageous)

Skills

• Time management
• Problem-solving
• Communication
• Leadership

Duties and Responsibilities

INTERNAL PROCESS

• Reporting and Reconciliation
• Prepare and submit the Monthly Fraud Debt Report and Executive Report for internal and board-level stakeholders.
• Compile and maintain the AOD(Acknowledgement of Debt) capital debt and recoveries excel sheet.
• Perform monthly reconciliations of recoveries including claims offsets,AODs, debt adjustments, and unallocated receipts.
• Legal Liaison and Case Management
• Coordinate and track monthly legal updates, ensuring input is received from scheme attorneys.
• Update forensic debt lists and circulate them to legal representatives for ongoing cases.
• Presentation and Stakeholder Communication
• Develop and review fraud debt presentation slides, working spreadsheets, charts, and dashboards prior to submission for governance meetings.
• Prepare materials for the Fraud Debt Management Meeting.
• Recovery Analysis and Tracking
• Maintain a recovery analysis tracker
• Track write-off recoveries and provide monthly reports on recovery efficiency.

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 healthcare providers and other parties to collect evidence regarding affordability to enter are payment agreement with the Scheme

PEOPLE

• Address conflicts constructively,mediate disputes and foster a more collaborative and harmonious work environment, strong communication skills are essential.
• Communicate clearly and assertively, while also being respectful and professional.
• Lead by example through strongwork ethic, integrity and respect towards all team members and all managers.

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.

As an applicant, please verify the legitimacy of this job advert on our company career page.-346021296