Manager: Claims Compliance & FWA

Description

• The main purpose of this position is responsible for the development, management and execution of the Company’s Fraud, Waste and Abuse (FWA) Management Programme and ensure claims compliance with the Fund rules, NAMAF billing rules, guidelines and relevant Acts, Regulations and Legislation and internal policies and processes

Duties

• Develop and manage the execution of FWA guidelines and protocols
• Manage and co-ordinate the process in identifying, collection data and information, monitoring, applying corrective measures and reporting Incidents of FWA
• Continuous engagement with members and/or healthcare providers to Identify FWA, provide clarify and explanations on Fund Rules, NAMAF billing rules, guidelines and relevant Acts and Regulations to ensure understanding of the concerns
• Engage with Funds, NAMAF, HPCNA and relevant stakeholders on all aspect pertaining to FWA, NAMAF billing rules, guidelines and the scope of practice of various disciplines
• Participate in stakeholder meetings, offering professional input, advice, and assistance to internal and external clients on the FWA, NAMAF billing rules and guidelines and other relevant Acts and Legislations
• Identify systems shortcomings, provide input on technical enhancements of the FWA Management Program and liaise with the programmers/IT/IS
• Compile report on FWA identified to relevant stakeholders

Requisites

• Degree as a Certified Fraud Examiner or similar qualifications, or a degree in health-related field
• Minimum 3 years practical business experience in a management or leadership role (essential)
• Minimum of 5 years' post qualification experience in compliance and risk management (essential)
• Experience in medical aid industry environment (desirable)
• Code BE driver’s license
• Competencies:
• Proficient with Microsoft products (Word, Excel, Outlook, PowerPoint)
• High levels of personal ethics, integrity, and emotional maturity
• Strong verbal, written, and interpersonal communication skills
• Ability to work well under pressure and independently
• Strong analytical and problem-solving skills
• Presentation and report writing skills
• Rule Orientation

Notes

• Only shortlisted applicants will be contacted