Forensic Specialist

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General Details
Advertised By:Agency
Job Type:Full-Time
Our client, a managed care company based in Cape Town, is looking for a confident, professional, motivated and well-spoken individual to fill this vacancy. They has been a leader in dental managed-care services since the mid nineties. Their extensive experience in dental risk management combines with cutting-edge technology to offer a world-class service relevant to the South African market.
Primary Role:

• The Forensic specialist performs in-depth profiling audits/investigations within the dental network environment
• The role is to review all outliers with irregular claiming activity as picked up and reported by the rest of business
• The forensic specialist identifies trends. Compile and analyse relevant data and review evidence gathered in order to report to relevant forum and forensic team
• Meet and or correspond with providers to validate claiming patterns and to identify the best course of action
• Investigate and identify providers for dental rehabilitation
• Actively contribute at Fraud Waste and Abuse and Risk Forums
• Generate reports and presentations for these meetings Job specification: Investigations

• Review all reported unusual profiles of dental providers
• Provide input on profiles and assist Profilers if and when needed
• Conduct forensic investigations and Identify trends
• Compile and analyse data for investigating bodies
• Generate reports for these bodies as well as for internal reporting and client meetings
• Request Profilers to conduct telephonic claims verification calls or send emails
• Correspond with providers to validate claiming patterns and identify the best course of action
• Ensure all Investigations are incorporated into workflow and auditable for data mining Rehabilitation of dental providers on the network

• Arrange and facilitate peer review meetings (formal/telephonic) once providers are identified for dental rehabilitation or sanctioning
• Send communication to provider and members related to rehabilitation if needed
• Investigate claiming patterns of providers on rehabilitation
System Analysis Case Management

• Ensure all FWA identifiers are codified and mapped into the companys systems for easy identification
• Review and design new FWA identifiers recommended for implementation into the system to grow knowledge base
• Lead and participate in various FWA campaigns approved by FWA Steering Committee Communications

• Contribution at FWA and Risk Forums
• Report back at the formal client meetings
• Compile reports and conduct professional presentations to clients Competencies:

• Excellent understanding of compliance regulations
• Ability to communicate effectively on all levels in both written and verbal format
• Problem definition and analysis
• Sound decision making
• Planning organising
• Teamwork
• Personal resilience
• Commitment to personal growth Qualifications / Skills / Experience: Qualifications:

• Grade 12
• Tertiary Diploma / Degree in rel...

Job Reference #: 201646

Id Subtitle 640964916
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