Quality Assurance Manager - Health

About Old Mutual

Old Mutual is a premium African financial services organisation that offers a broad spectrum of financial solutions to retail and corporate customers across key market segments in 14 countries. The lines of business include Life and Savings, Property and Casualty, Asset Management and Banking and Lending. We are rooted in our purpose of Championing Mutually Positive Futures Every Day and believe that a great customer experience is anchored in a great employee experience.

About the Role

The Health Insurance QA Manager is responsible for ensuring that claims, case processes, and services meet established standards to guarantee efficiency, mitigate losses, and prepare controls for managing claims costs.

Key Responsibilities

Quality Audits of Claims

• Conduct an audit of overall claims settled, placing special attention to high-value, repeated visits, and duplicate claims
• Check error rate
• Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagements issues on billing
• At the end stage of provider reconciliation, review claims that relate to benefit excesses and assign liability to either UAP, client/scheme or Smart
• Track admissions; check on exaggerated bills, unnecessary admissions, or overstay admissions
• Review the integration exception report between E02 and D365

Claims Analysis and Cost Control

• Conduct trending analysis; identify leakage; and prepare objective reports on claims and case processing processes
• Enforce claims cost controls, e.g., copayments, discounts, provider restrictions, waiting periods
• Monitor and ensure compliance with SOPs for claims, case, and provider management
• Manage reserve philosophy for admission/approval and enhanced amounts
• Review IP bills for scheduled cases on a monthly basis
• Review reimbursement reports to pick exceptions and conduct cold calling/impromptu visits

Training and Process Development

• Contribute to the development of process-specific, competency-based training
• Identify knowledge gaps and training needs of the claims and case team
• Identify gaps in policy terms and review together with the retention team
• From the findings of the audit of IP and OP settled claims, give recommendations and remedial actions
• Drive the implementation of said actions

Reporting and Monitoring

• Prepare reports to communicate outcomes of quality activities
• Monitor and share reports of TATs for all key claims processes
• Track claims paid in E02 vs D365; use of the exception reports to monitor paid, reversed, and cancelled claims
• Prepare regular claims reports to management and advise the underwriter on relevant claims findings for medical risk review
• Root cause and close out

Systems and Risk Management

• Continuously review the effectiveness of workflow systems and recommend enhancements
• Provide input on ML and core system enhancements to improve quality and output
• Monitor risk management activities: GIA issues

Client Service and Fraud Investigation

• Resolve difficult client enquiries; ensure timely completion of investigations/resolution arising from claims disputes in case management and claims teams
• Investigate suspected fraud issues; guide the fraud reporting to GFS and follow up to closure

Team Development

• Coach, counsel, or train less-experienced staff
• Provide input in the performance management, goal setting, and review processes

Core Competencies

• Aligns Execution – Planning and prioritizing work to meet commitments aligned with organizational goals
• Manages Complexity – Making sense of complex, high volume and sometimes contradictory information to effectively solve problems
• Builds Effective Teams – Building strong-identity teams that apply their diverse skills and perspectives to achieve common goals
• Ensures Accountability – Holding self and others accountable for meeting commitments
• Business Insight – Applying knowledge of business and the marketplace to advance organizational goals
• Strategic Vision – Seeing ahead to future possibilities and translating them into breakthrough strategies
• Drives Results – Consistently achieving results, even under tough circumstances
• Customer Focus – Provides cautious, timely and helpful service to encourage client loyalty
• Engages & Inspires – Creating a climate in which people are motivated to do their best to help the organization achieve its objectives
• Instils Trust – Gaining the confidence and trust of others through honesty, integrity, and authenticity
• Cultivates Innovation – Creating new and better ways for the organization to be successful
• Develops Talent – Developing staff capabilities and potential
• Bio Statistics skills are key

Required Knowledge and Experience

• Minimum of 5 years of experience in clinical operations, claims processing, or a related field
• In-depth knowledge of Quality Assurance, claims processing, and regulatory requirements

Required Qualifications

• Bachelor's degree in Healthcare Administration, Nursing, or a related field
• Relevant certifications in healthcare management or clinical operations are preferred
• NQF Level 7 – Degree, Advance Diploma or Postgraduate Certificate or equivalent

Anti-Money Laundering (AML) Expectation

The incumbent will be responsible for ensuring adherence to, implementation of, and adoption of Compliance, Anti-Money Laundering (AML), and Sanctions-related policies, procedures, and process requirements within Old Mutual and its subsidiaries. This includes:

• Execution of customer due diligence processes
• Ensuring compliance with Know-Your-Customer (KYC) standards
• Conducting ongoing and enhanced due diligence
• Maintaining data quality
• Identifying and monitoring potential AML, Sanctions, or Compliance breaches and unusual activities
• Escalating concerns to the Risk and Compliance Office for further action

AML-Related Skills: Action Planning, Claims Management, Data Compilation, Data Controls, Executing Plans, Financial Auditing, Insurance Claims Investigations, Oral Communications, Policies & Procedures, Typology

Closing Date

02 June 2026, 23:59