Manager: GEMS Claims Risk Management

The role incumbent will be responsible for managing and guiding a team focused on proactive risk identification, by bringing a systematic and structured approach to adjudicating financial risk to client schemes. Activities will be directed at preventing future losses due to Fraud, Waste, and Abuse (FWA) primarily in the prepayment domain, through interventions on specific practices but also through enhanced system controls. The role incumbent will also oversee the analytical review of the claims profiles of selected healthcare service providers, identify significant claims risk seen in anomalous claiming patterns, and make recommendations to the broader team on actions to mitigate this risk. Effective management of this team will ensure better outcomes for our clients.