Claims Audit Manager – Pretoria

About the role

The Claims Audit Manager will lead the efficient management of backlog claim files and audit initiatives. This role ensures that claim status determination, routing, and closure recommendations are performed accurately and in line with policy. The manager will also oversee quality assurance and exception handling to mitigate operational and legal risks.

Key responsibilities

• Review and implement departmental policies, procedures and processes.
• Manage backlog audit initiatives and operate the Audit Hub for claim status determination, routing, readiness certification and closure recommendation.
• Ensure mortality verification, claimant validation and outstanding information identification are performed according to scope.
• Oversee product‑stream classification for funeral, loss of support, general damages and loss of earnings matters.
• Route claims with clear work plans and next actions to reduce rework and improve throughput.
• Monitor hub performance against productivity, quality, ageing, dependency and routing requirements.
• Identify and mitigate operational, legal, financial, compliance, quality and reputational risks arising from backlog audit activities.
• Recommend process improvements, control enhancements and corrective actions.
• Establish and monitor quality‑assurance standards for claim audits, routing decisions, readiness assessments and closure recommendations.
• Conduct quality reviews covering mortality verification, system reconciliation, prescription recording, payment history, product classification and status determination.
• Manage exception handling for complex, dormant, litigated, prescribed, system‑discrepant, medical/HPCSA, court‑order and writ‑linked matters.
• Maintain and review exception registers and escalate critical issues to legal, compliance or executive structures.
• Produce operational reports on audit volumes, claim status outcomes, stage ageing, routing, quality, exceptions and legal exposure.

Required profile

• Proven experience managing insurance claim audit backlogs.
• Strong knowledge of mortality verification, claimant validation and product‑stream classification.
• Ability to monitor performance metrics and manage operational risks.
• Experience establishing quality‑assurance standards and conducting detailed audit reviews.
• Competence in handling complex exception cases and coordinating with legal and compliance teams.

Required skills