Location: Centurion, Gauteng

Position Purpose: The Non-Disclosure Investigator is responsible for identifying and investigating suspected cases of member non-disclosure, misrepresentation, or omission of material medical information during the application process for medical scheme membership.

The role is responsible for assessing whether medical conditions, symptoms, treatments, or consultations existed prior to scheme application and whether these were appropriately disclosed during underwriting.

The investigator supports the protection of the Scheme against financial and underwriting risk through detailed clinical, claims, and membership investigations while ensuring compliance with legislation, scheme rules, and governance requirements.

Experience: Extensive Experience (3-5 years) in Hospital authorisations, Claims Investigations, non-disclosure investigations, with demonstrated expertise in gathering evidence, analysing clinical information and identifying risk is essential. 

Qualification: Degree or diploma in Forensics, Clinical qualification, Healthcare Administration, Risk Management

Knowledge & Technical Skills

• Strong understanding of:

• • Medical scheme operations
  • Underwriting and waiting periods
  • PMB legislation
  • Hospital and specialist billing environments
  • Clinical coding (ICD-10, tariff codes)
  • Fraud, Waste & Abuse methodology
• Ability to analyse claims trends and clinical histories.
• Strong report-writing and investigative skills.
• Advanced analytical and problem-solving ability.

Competencies

• Investigative mindset
• High attention to detail
• Strong analytical capability
• Efficient time management skills
• Ethical judgement and professionalism
• Excellent written and verbal communication
• Ability to manage sensitive and complex investigations
• Strong stakeholder engagement skills
• Ability to work independently and under pressure

• Review membership application forms, underwriting declarations, and supporting documents.
• Assess whether pre-existing conditions, symptoms, consultations, investigations, or treatments existed prior to membership inception.
• Establish clinical and treatment timelines in relation to application and joining dates.
• Determine materiality and potential impact of non-disclosure on risk acceptance and claims exposure.

• Request additional information where required to support investigations.

Compliance & Governance

• Ensure all investigations comply with:
  • Medical Schemes Act
  • POPIA
  • CMS guidelines
  • Internal governance frameworks
  • Scheme underwriting rules
• Maintain confidentiality and integrity of member and clinical information.
• Ensure all case documentation is audit-ready and within the ambit of the Medical Schemes Act 131 of 1998 and the Scheme rules.
• Knowledge of compliance regulations and reporting standards applicable to the industry

Note: Company reserves the right to close the advert before specified closing date.