Role Purpose
The Claims Early Warning Specialist is responsible for proactively identifying emerging risks, unusual patterns, system anomalies, and potential claims leakage within the medical aid environment.
The role supports early detection of irregular claims behaviours, provider risk indicators, member utilisation spikes, and operational bottlenecks to prevent financial losses and ensure compliance with scheme rules and regulatory expectations.
The incumbent works closely with Claims, Managed Care, Forensics, Actuarial, Finance, IT/Data, and Provider Networks to ensure risks are mitigated early and effectively.
Requirements
National Diploma or Bachelor's degree in Health Sciences, Information Systems, Statistics, Data Analytics, Fraud Risk Management, or related field
2 - 5 years' experience in claims risk, claims processing, forensics, analytics, or managed care within a medical aid or healthcare environment
Understanding of claims workflows, PMB rules, ICD-10, tariff coding, provider billing patterns, and scheme benefit structures
Experience using analytics tools (Excel, Power BI, SQL, or similar) is highly advantageous
Knowledge of Medical Schemes Act, CMS regulations, and POPIA
Duties & Responsibilities
Monitor daily and weekly claims trends to identify early warning signals such as cost spikes, sudden utilisation increases, unusual coding patterns, and high-risk provider behaviour.
Use dashboards, exception reports, and rules-based alerts to detect potential claims leakage, incorrect benefit allocation, or processing errors.
Flag high-risk claims for review and escalate to Forensics, Managed Care, or Claims Management as required.
Validate and investigate claims anomalies related to PMBs, chronic benefits, tariff mismatches, and benefit limits.
Collaborate with IT/Data teams to refine and enhance early warning rules, algorithms, and reporting dashboards.
Work with Claims Processing teams to reduce rework, improve accuracy, and identify root causes of recurring errors.
Support Provider Relations with insights on outlier behaviour, suspicious billing, and quality-of-care concerns.
Prepare daily and weekly risk summaries for leadership, highlighting material risks, trends, and recommended mitigations.
Ensure all analysis and escalations align with POPIA, CMS guidelines, and medical scheme rules.
Assist with continuous improvement initiatives related to claims efficiency, fraud mitigation, and benefit optimisation.
Competencies
Strong analytical and investigative ability with attention to detail.
Ability to interpret claims and utilisation data to identify trends and anomalies.
Good communication and stakeholder-management skills.
Critical-thinking and problem-solving capabilities.
Ability to work under pressure and manage competing priorities.
High ethical conduct when handling sensitive member and provider information.
Closing Date
2026/04/05