Claims Risk Assessor

Efficiently and effectively manage allegations related to fraud, waste, and abuse within the medical industry. This role involves receiving, analysing, and investigating allegations, validating their credibility, and assessing the need for further action. The Assessor will also provide critical support in data retrieval for internal and external stakeholders. 

Allegations Management

• Receive and document allegations related to fraud, waste, and abuse within the medical industry.
• Load allegations onto the case management system accurately and promptly.
• Ensure compliance with relevant healthcare and legal regulations.

Acknowledgment and Communication

• Send acknowledgment letters to complainants within 24 hours of receiving allegations.
• Notify relevant parties and request comments regarding the allegations.

Preliminary Investigation

• Utilize analytical tools to assess the validity of allegations.
• Review available evidence and information to make a preliminary determination.
• Determine whether a desktop investigation is needed.

Turnaround Time

• Complete the entire assessment process within a strict 7-day turnaround time.
• Manage workload and prioritize tasks to meet deadlines effectively.

Data Retrieval

• Search the case management system and relevant document repositories to provide internal and external stakeholders with requested data.
• Fulfill data requests within 5 days of receipt.

Volume Management

• Handle high volumes of allegations and data requests, adapting to fluctuations in workload.

Documentation

• Maintain detailed and accurate diary entries of all activities and assessments.
• Ensure all documentation meets high-quality standards and compliance requirements with the Administration Agreement, Client Standard Operating Procedure Documents and internal processes.

Compliance

• Adhere to all relevant healthcare, legal, and compliance policies and procedures.

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.
• Make recommendations to improve client service and fair treatment of clients within area of responsibility.
• Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
• Continuously monitor turnaround times and quality standards and resolve issues speedily to enhance client service delivery.
• Drive client service delivery goal achievement in line with predefined standards in order to ensure that clients receive appropriate advice and after sales service.
• Manage client query processes and ensure that queries are tracked, accurately resolved and used as a mechanism to improve client service and business processes.

People

• Build strong relationships through providing specialist know-how and leadership to others, expressing positive expectations.
• Continuously develop own expertise in terms of industry and subject matter development and application thereof in an area of specialization.
• Positively influence and manage change and offer specialist support where required.
• Contribute to continuous innovation through the development, sharing and implementation of new ideas and involvement of colleagues and staff.
• Participate and contribute to a culture of work centric thinking, productivity, service delivery and quality management.
• Take ownership for driving career development.

Finance

• Contribute to the development of area specific budgets to minimise expenditure, in alignment with operational plans.
• 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.

APPLY HERE