Job Description

Closing Date 2025/05/26
Reference Number MMH250416-2
Job Title Claims Risk Specialist
Position Type Permanent
Role Family Risk
Cluster Momentum Health
Remote Opportunity Some of the time
Location - Country South Africa
Location - Province Western Cape
Location - Town / City Bellville
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 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
• Bachelors degree in finance, accounting or auditing with financial auditing major or related field.

Experience

• 3 - 5 years experience in a similar or closely comparable role at managerial level

Knowledge

• Strong analytical and reconciliation skills
• Proficiency in Excel (including pivot tables, 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 & 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 a repayment 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 strong work 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.

Competencies

• Attention to detail
• Confidentiality
• Adherence to regulations
• Teamwork
• Professionalism
• Adaptability

Policy
We are committed to Employment Equity, diversity and inclusion when recruiting internally and externally. All appointments are made in alignment to our Employment Equity goals and we encourage people with disabilities to apply.