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Job Description

Ensure effective specialised investigation of Claims to minimise fraud.

Determining the merits of the claim - fraudulent versus legitimate.

Report findings of investigation in an effective and unbiased manner.

Conduct presentations on fraud awareness – Red Flags.

Ensure the timeous identification, if possible, of fraudulent claims, resulting in monetary savings for the company.

Ensure data is quality controlled.

Effectively communicate and give feedback to clients, staff, and call centre as required.

Analyse query and complaints trends and suggest solutions.

Prepare periodic reports and presentations on project progress, issues and progress against timeline reports/updates.

Maintain service, quality and desired outputs within a specific functional process through ensuring compliance to tactical policies, procedures and standards.

Resolve escalated customer queries and complaints and provide feedback to customers on matters resolved.

Develop work routines in line with operational plans / schedules in order to manage achievement of service delivery goals

Measure and monitor service delivery compliance of team.

Share knowledge on, and participate in the creation of new standards, control systems and procedures to maintain service delivery.

Align own behaviour with the organisation culture and values.

Share and transfer product, process and systems knowledge to colleagues.

Collaborate and work with the Claims team to ensure required service levels are delivered.

Actively participate in the Claims team to ensure functional balanced scorecard objectives are achieved.

Ensure achievement of own performance objectives.

Actively share information with other team members regarding successes, issues, trends and ideas.

Actively participate in own professional development and career path.

Track and resolve operational and performance variations

Develop and encourage strong team work

Identify potential inter-departmental problems and escalate them to higher levels

Engage regularly in team or group problem-solving

Manage areas of critical compliance and actively manage non-conformance

Actively manage non-performance

Take accountability for the management of business related risks within own area.

Operate within agreed mandates as documented in the business rules.

Requirements:

Proven track record with on-the-road investigations

10 years on-the-road investigations experience.

Some experience in leading a team, desktop or on-the-road would be beneficial​​

Conducts, oversees and manages fraudulent insurance claims in order to contain claims spend and to provide excellent service in setting a culture of best practice within mandated responsibility. Provides guidance in complex cases

ResponsibilitiesFraud/Financial Crime Investigation

Investigate cases of suspected fraud or financial crime. Identify lines of inquiry, and gather and retain information and physical or electronic evidence to support criminal investigation and/or legal action, engaging specialist investigators or subject-matter experts where necessary. Review the evidence gathered and recommend appropriate action to the organization.

Insurance Claims Evaluation

Investigate the circumstances of claims and the nature and extent of clients' losses. Review and evaluate information gathered using own subject-matter expertise, and examine additional evidence provided by specialist investigators or subject-matter experts to determine the extent of liability. Negotiate settlement of insured losses in line with delegated authority.

Fraud/Financial Crime Management

Deliver fraud prevention reporting and analysis for a designated area of operations, using financial crime/fraud prevention systems to identify instances, patterns, and trends of suspicious activity, to enable the prevention of fraud and enable the initiation of loss mitigations and fraud investigations.

Fraud/Financial Crime-Management Systems Development

Research and identify fraud trends and emerging risks, contribute to the drafting of fraud prevention policies and procedures, and identify opportunities for new and/or improved anti-fraud systems functionalities to support the development of fraud/financial crime prevention strategies, policies, procedures, and monitoring systems.

Regulatory and Compliance Management

Investigate all kinds of incidents and reports and provide expert advice to more senior colleagues. Minimize risk exposures and ensure adherence with regulatory standards by working with all internal functions to make sure compliance programs are properly implemented.

Financial Management and Control

Work within established systems to deliver prescribed outcomes for a designated area of financial control.

Insurance Claims Administration

Review and analyze assigned insurance claims in line with the organization's standard claims procedures and customer service standards. Engage loss adjusters and/or subject-matter experts where appropriate, authorize claims within delegated authority, and refer complex or unresolved issues to senior colleagues.

Insights and Reporting

Contribute to the preparation of various data and analytics reports.

Stakeholder Engagement

Assist with stakeholder engagement by arranging actions, meetings, events, and supporting materials to promote stakeholder understanding and commitment.

Operational Compliance

Identify, within the team, instances of noncompliance with the organization's policies and procedures and/or relevant regulatory codes and codes of conduct, reporting these instances and escalating issues as appropriate.

Personal Capability Building

Develop own capabilities by participating in assessment and development planning activities as well as formal and informal training and coaching; gain or maintain external professional accreditation, where relevant, to improve performance and fulfill personal potential. Maintain an understanding of relevant technology, external regulation, and industry best practices through ongoing education, attending conferences, and reading specialist media.

Skills

Action Planning, Claims Management, Data Compilation, Data Controls, Executing Plans, Financial Auditing, Insurance Claims Investigations, Typology

Competencies

Action OrientedBusiness InsightCollaboratesDecision QualityFinancial AcumenInstills TrustManages ComplexityOptimizes Work Processes

Education

NQF Level 7 - Degree, Advance Diploma or Postgraduate Certificate or equivalent

Closing Date

25 March 2025 , 23:59

The appointment will be made from the designated group in line with the Employment Equity Plan of Old Mutual South Africa and the specific business unit in question.

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