Job Description

Closing Date 2026/01/23
Reference Number MMH260113-4
Job Title Senior Claims Risk Assessor
Position Type Permanent
Role Family Medical
Cluster Momentum Health
Remote Opportunity Some of the time
Location - Country South Africa
Location - Province Western Cape
Location - Town / City Bellville, Cape Town
Introduction
Through our client-facing brands Momentum Group, 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.
Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.
Role Purpose
Preliminary analysis and investigation of allegations related to fraud, waste, and abuse within the medical claims environment.
Requirements
QUALIFICATIONS

• Matric
• Bachelor's degree, diploma or higher certificate in a relevant field (e.g., healthcare, law, auditing, forensics)
• Association of Certified Fraud Examiners (ACFE)
• Certification in fraud examination, healthcare compliance or a related field (desirable)

EXPERIENCE

• 5 years experience in medical aid claims investigation or claims adjudication

KNOWLEDGE

• Proven experience in healthcare compliance and fraud investigation, with expertise in healthcare fraud, waste, and abuse (advantageous)
• Proven clinical expertise or knowledge (advantageous)
• Strong analytical and research skills, with experience using various analytical tools to conduct desktop investigations
• Excellent written and verbal communication skills

Duties & Responsibilities
PROCESS
Allegations Management:

• Oversee and facilitate the efficient receipt and documentation of allegations related to fraud, waste, and abuse.
• Ensure accurate and prompt loading and equitable distribution of allegations onto the case management system and within the team.

Acknowledgment and Communication:

• Supervise the timely distribution of acknowledgment letters to complainants within 24 hours of receiving allegations.
• Manage notifications to relevant parties and request comments regarding the allegations.

Preliminary Investigation:

• Lead the use of analytical tools to assess the credibility of allegations.
• Ensure thorough reviews of available evidence and information, identifying more complex investigations early on and making preliminary determinations with a tighter turnaround time than Claims Risk Assessors.
• Determine whether a full-scale investigation is warranted with a 50% tighter turnaround time.

Full Investigations:

• Conduct full investigations for hotline complaints assessed as low risk profiles but with valid disputed claims with the turnaround time stipulated.
• Ensure that full investigations are conducted meticulously and in compliance with all relevant policies, SOPs and regulations.

Process Improvement:

• Facilitate and take ownership of implementing process improvements to enhance the efficiency and effectiveness of the investigative process, becoming a culture champion for positive change.

Limited Leadership:

• Temporarily step into a limited leadership capacity when required, providing guidance and support to the team.

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 members, healthcare providers and other parties to collect evidence regarding questionable claims.
• Provide expert guidance and support to existing investigators on complex cases and assist in their professional development.

PEOPLE

• The successful candidate should be able to address conflicts constructively, mediate disputes and foster a more collaborative and harmonious work environment.
• Strong communication skills are essential. The successful candidate should be able to 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. Even though this role may not have direct managerial authority, strong leadership qualities are essential.

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

• Time management
• Attention to detail
• Problem-solving
• Communication
• Adherence to regulations
• Professionalism: Uphold the highest standards of ethics, integrity and confidentiality in decision-making and actions.
• Expertise: Demonstrate a high level of expertise in healthcare fraud, waste, and abuse investigation.
• Adaptability: Be flexible and willing to step into a limited leadership role when required.
• Teamwork and Leadership: Proven track record of uniting individuals constructively toward a common goal, embodying values of performance excellence and integrity, making it a true culture champion.

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.

Skills Required