Senior Forensic Investigator MMH260120-12

Momentum; Bellville; Presencial; ZAR 850.000 - 1.100.000; Jornada completa

Descripción de la vacante

Momentum in South Africa seeks a Senior Forensic Investigator to lead investigations into complex fraud, waste, and abuse within medical aid administration. The role blends forensic expertise with strategic oversight and leadership, guiding investigations and developing processes.

You will analyze medical records and billing data, apply tariff codes, and prepare comprehensive reports for clients and regulators. Travel is minimal, and the role is office-based with desktop analysis.

Formación

• Matric / Grade 12 (essential).
• Bachelor’s degree in Healthcare Management, Finance, Accounting, Forensics, or a related field (essential).
• Minimum of 5 years of experience in healthcare fraud investigations, medical aid schemes administration, or related fields (essential).
• Proven track record of managing and conducting complex investigations (essential).
• Certification in fraud examination, healthcare compliance or a related field (desirable).
• Proven experience in healthcare compliance and fraud investigation, with expertise in healthcare fraud, waste, and abuse.
• Proven clinical expertise or knowledge.
• Strong analytical and research skills, with experience using various analytical tools to conduct desktop investigations.
• Excellent written and verbal communication skills.
• Exceptional attention to detail.
• Deep understanding of medical tariff codes, billing practices, and healthcare reimbursement methodologies.

Responsabilidades

• Lead Complex Investigations.
• Manage and conduct detailed desktop investigations into syndicate groups or complex cases of fraud, waste, and abuse within healthcare claims.
• Analyse medical records, claims data, and billing statements to identify discrepancies, anomalies, and potentially fraudulent activities.
• Use advanced knowledge of medical aid schemes, policies, and procedures to assess claim validity and detect fraud.
• Apply medical tariff codes and billing guidelines to ensure accuracy and appropriateness of billed services.
• Build and maintain relationships with clients and internal and external stakeholders.
• Deliver on service level agreements applicable to clients and internal and external stakeholders to ensure that client expectations are effectively managed.
• Participate in and contribute to a culture that builds rewarding relationships, facilitates feedback, and delivers exceptional client service.
• Collaborate with internal teams, including data analysts, clinical advisors, and other forensic investigators, to gather and validate evidence.
• Conduct interviews with members, healthcare providers, and other relevant parties to collect and corroborate evidence.
• Prepare comprehensive investigation reports to be presented to client summarising findings, conclusions, and recommendations for remedial actions.
• Ensure reports are clear, well drafted, accurate, and actionable for both internal stakeholders and external regulatory bodies.
• Testify as an expert witness in legal, regulatory, and disciplinary proceedings based on investigation findings.
• Willingness to travel (locally) as needed for investigations, court appearances, and meetings.
• Office-based investigation role with virtual engagements with members and providers; no field work.
• Contribute to development and enhancement of investigation processes, methodologies, and best practices.
• Provide expert guidance and support to existing investigators on complex cases and assist in their professional development.

Conocimientos

Forensic investigations

Healthcare fraud

Data analysis

Stakeholder communication

Legal testimony

Educación

Bachelor’s degree in Healthcare Management, Finance, Accounting, Forensics, or related field

Matric / Grade 12

Descripción del empleo

Role Purpose

The Senior Forensic Investigator will lead and conduct in-depth investigations into complex cases of fraud, waste, and abuse within the medical aid administration industry. This role bridges the technical expertise of a forensic investigator with strategic oversight and leadership, providing expert guidance on investigations, collaborating with stakeholders, and contributing to the development of investigation processes and projects. The ideal candidate will have a strong background in medical aid schemes and forensic investigations, with the ability to drive high-quality results and support the professional development of team members.

Qualifications

• Matric / Grade 12 (essential).


• Bachelor’s degree in Healthcare Management, Finance, Accounting, Forensics, or a related field (essential).

Experience

• Minimum of 5 years of experience in healthcare fraud investigations, medical aid schemes administration, or related fields (essential).


• Proven track record of managing and conducting complex investigations (essential).


• Certification in fraud examination, healthcare compliance or a related field (desirable).

Knowledge

• Proven experience in healthcare compliance and fraud investigation, with expertise in healthcare fraud, waste, and abuse.


• Proven clinical expertise or knowledge.


• Strong analytical and research skills, with experience using various analytical tools to conduct desktop investigations.


• Excellent written and verbal communication skills.


• Exceptional attention to detail.


• Deep understanding of medical tariff codes, billing practices, and healthcare reimbursement methodologies.

Duties and Responsibilities

Process

• Lead Complex Investigations.


• Manage and conduct detailed desktop investigations into syndicate groups or complex cases of fraud, waste, and abuse within healthcare claims.


• Analyse medical records, claims data, and billing statements to identify discrepancies, anomalies, and potentially fraudulent activities.


• Use your advanced knowledge of medical aid schemes, policies, and procedures to assess claim validity and detect fraud.


• Apply medical tariff codes and billing guidelines to ensure accuracy andappropriateness of billed services.

Client

• Build and maintain relationships with clients and internal and external stakeholder.


• Deliver on service level agreements applicable to clients and internal and external stakeholders to ensure that client expectations are effectively managed.


• Participate in and contribute to a culture that builds rewarding relationships, facilitates feedback, and delivers exceptional client service.


• Collaborate with internal teams, including data analysts, clinical advisors, and other forensic investigators, to gather and validate evidence


• Conduct interviews with members, healthcare providers, and other relevant parties to collect and corroborate evidence.


• Prepare comprehensive investigation reports to be presented to client summarising findings, conclusions, and recommendations for remedial actions.


• Ensure reports are clear, well drafted, accurate, and actionable for both internal stakeholders and external regulatory bodies.


• Testify as an expert witness in legal, regulatory, and disciplinary proceedings based on investigation findings.


• Willingness to travel (locally) as needed for investigations, court appearances, and meetings. Travel is minimal to none however they may be a need if requested by client.


• Office-based investigation role with virtual engagements with members and providers. Kindly note there is no field work involved and all analysis and investigations are performed strictly on a desktop level.


• Contribute to the development and enhancement of investigation processes, methodologies, and best practices.


• 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.


• 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.