Claims Risk Specialist

Momentum Group Limited; Bellville; On-site; ZAR 30 000 - 50 000; Full time

Job summary

A leading financial services company is seeking a Fraud Recovery Manager to oversee the recovery of fraud-related debts from healthcare providers. The role involves managing debt acknowledgment processes, ensuring compliance with regulations, and producing executive reports. Ideal candidates will have a Bachelor's degree in finance or accounting, strong analytical skills, and 3-5 years of managerial experience in a similar role.

Qualifications

• Matric required.
• 3-5 years’ experience in a similar managerial role.
• Strong analytical and reconciliation skills.

Responsibilities

• Lead and coordinate recovery of fraud, waste, and abuse debt.
• Prepare monthly fraud debt reports for stakeholders.
• Build and maintain relationships with clients and stakeholders.

Skills

Time management

Problem-solving

Communication

Leadership

Education

Bachelor’s degree in finance, accounting, or auditing

Tools

Excel

Job description

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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 acknowledgment 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 identified as anomalous claimers.

Requirements Qualifications

• Matric
• Bachelor’s degree in finance, accounting, or auditing with a 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 stakeholders to ensure expectations are managed
• Participate and contribute to a culture that builds rewarding relationships, facilitates feedback, and provides exceptional client service. Interview healthcare providers and other parties to collect evidence regarding affordability for repayment agreements with the Scheme.

People

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

Finance

• Identify solutions to enhance cost-effectiveness and operational efficiency.
• Implement and provide input into governance processes, systems, and legislation within your area of specialization.
• Escalate unresolved policy and compliance issues for investigation and resolution.
• Contribute to risk identification processes and communicate recommendations appropriately.

Competencies

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

Seniority level

• Mid-Senior level

Employment type

• Full-time

Job function

• Finance and Sales