Forensic Investigator

Position

Purpose:

To identify, investigate, and assist in the prevention of fraud, waste and abuse within the medical aid environment. This includes but is not limited to analysing healthcare provider claims, member behaviour and internal operations to mitigate financial and reputational risks.

Experience: Extensive Experience (3-5 years) in forensic investigation, with demonstrated expertise in gathering evidence, analysing data and leading investigations.

Qualification: Degree or diploma in Forensics, CFE.

• Identify and investigate suspected fraudulent and irregular claims or transactions.
• Conduct interviews, gather evidence, and compile forensic reports.
• Liaise with healthcare and other service providers, members, internal departments, regulatory bodies and external law enforcement where required.

Data Analysis

• Analyse claims data to identify patterns, anomalies, or trends indicative of fraud, waste, or abuse.
• Use analytic tools to monitor suspicious billing, over-servicing, or coding anomalies.
• Reviewing application forms for any discrepancies
• Knowledge of healthcare provider billing rules and coding

Compliance & Legal

• Ensure compliance with internal policies and regulatory frameworks (POPIA, FAIS, Medical Schemes Act, Scheme Rules etc.).
• Prepare and store documentation for each investigation, internal hearings, litigation, or regulatory referrals.
• Recommend disciplinary, civil, or criminal action where applicable.

Reporting & Documentation

• Written and verbal interactions with providers, members and other stakeholders
• Draft detailed investigation reports with findings, evidence, and recommendations.
• Maintain accurate, confidential case records in line with legal and policy requirements.
• Compile all of the documents required to report the matter externally
• Record all of the information on the case management system

Preventive Measures

• Support development of fraud prevention strategies, education, and awareness campaigns.
• Recommend process improvements to minimize future fraud risks and implement proactive measures to mitigate the potential risk

Collaboration & Stakeholder Management

• Work with medical aid administrators, actuaries, legal advisors, and third-party investigators.
• Represent the organization in engagements with the perpetrator, the client, regulators and industry bodies when necessary.

Skills and Abilities

• Ethical and professional integrity
• Analytical thinking
• Excellent communication and interviewing skills
• Ability to manage confidential and sensitive information
• Sound judgement and problem-solving skills
• Ability to work under pressure and manage multiple cases
• Understanding of billing processes, ICD-10 coding, procedure codes and billing rules and medical scheme requirements.
• Excellent attention to detail and numerical accuracy.
• Efficient time management
• Advanced MS Excel

Knowledge

• Fraud, Waste, and Abuse (FWA) in a managed care organisation.
• Data Analysis & Forensic Tools
• Legal and Compliance Frameworks
• Sound knowledge of medical aid industry laws and regulations.
• Knowledge and application of billing processes and procedures
• Knowledge of compliance regulations and reporting standards applicable to the industry

Note:
Company reserves the right to close the advert before specified closing date.

PHA has its head office in Westville, Kwa Zulu-Natal. It operates country-wide with a nationally linked network and uses a robust, flexible, as well as integrated system to ensure efficient and effective administration of membership and benefits.