We’re on the lookout for exceptional individuals who have clinical education and experience to join our dynamic team and contribute to our mission of redefining success in the global health and life insurance industry.
Position Title: Claims Auditor
Reports to: Head of Operations Support
Department: Insurance Operations
Location: Hybrid (Johannesburg, South Arica)
Job Type: Fixed Term Contractor
WHY WORK WITH US?
At Unisure, we’re more than just a workplace – we’re a community of innovators, collaborators, and changemakers. Here’s what you can expect:
- Competitive Pay & Benefits: A market-leading salary and benefits package that rewards your expertise and impact.
- Flexible Work-Life Balance: Hybrid work options to support your personal and professional life.
- Growth Opportunities: Access to career development programs and leadership training.
- Supportive Culture: We celebrate diversity, inclusion, and the unique perspectives that each team member brings.
ABOUT THE ROLE
The Claims Auditor is responsible for conducting detailed pre–payment claim audits to identify suspicious claims, ensure accuracy, and mitigate fraud risks before payment is processed. This role is a proactive safeguard against fraudulent or invalid claims, reducing financial exposure to the organization. The successful candidate must possess strong clinical expertise to assess medical claims effectively and validate treatments before payment approval.
KEY ROLE AND RESPONSIBILITIES:
Pre-payment Claims Auditing & Validation:
- Conduct regular audits of processed claims to identify discrepancies, fraud, and errors.
- Manage a list of suspicious claimants and conduct detailed audits before payment is approved.
- Perform sample audits on other claims to detect anomalies and ensure compliance with policy terms.
- Call medical service providers to verify treatments, procedures, and hospitalization claims before payment.
- Validate claims against medical records, test results, and utilization histories.
- Ensure claims decisions align with policy conditions, ethical standards, and regulatory requirements.
- Maintain detailed records of audit processes, decisions, and outcomes.
Fraud Prevention & Risk Assessment:
- Identify potential fraudulent claims, abuse, and overbilling before payments are made.
- Escalate high-risk claims to the risk and legal departments for further investigation.
- Stay updated on industry fraud trends and emerging risk mitigation practices.
Stakeholder Collaboration & Communication:
- Collaborate with claims teams, risk management, and legal departments.
- Clearly communicate audit findings and recommendations to senior management.
- Address inquiries from policyholders regarding audit decisions.
- Ensure strict compliance with internal policies and industry regulations.
WHAT YOU’LL BRING
-
MUST HAVE a clinical education and qualification (Nursing, Medicine, paramedic). **Please do not apply
if you do not have this.
- MUST HAVE a clinical education and qualification (Nursing, Medicine, paramedic). **Please do not apply if you do not have this.
- MUST HAVE: Minimum 3 - 5 years of clinical experience. **Please do not apply if you do not have this.
- Experience in pre-payment claims validation is highly advantageous.
- Proficiency in claims management systems and investigative tools.
Skills in:
- Clinical Expertise: Strong understanding of medical terminology, conditions, and treatments.
- Critical Thinking: Ability to assess medical and financial documents to detect inconsistencies.
- Attention to Detail: Strong capability to identify fraudulent claims and audit inconsistencies.
- Communication & Verification: Experience in contacting healthcare providers for claim validation.
- Regulatory Compliance: Knowledge of insurance policies and industry fraud detection strategies.
READY TO MAKE YOUR MARK?
At Unisure, you’ll be empowered to lead, innovate, and grow while shaping the future of our industry. If you’re excited about making an impact and working with an amazing team, we’d love to hear from you! Unisure is an equal opportunity employer.