Tasneem Sheik Ebrahim

Timeline as Forensic Investigator :
Forensic Investigator - August 2015 to December 2019
Senior Forensic Investigator - January 2020 to December 2020
Senior Forensic Investigator Associate Specialist - January 2021 to Current

Investigation Skills
- Investigating member fraud e.g., false applications and claims
- Coordinating probe investigation or surveillance for any theft related cases
- Staff investigation and disciplinary hearings on corruption and money laundering
- Testifying in disciplinary hearings
- Report writing and recommendation
- Applying other fraud risk initiatives with relevant stakeholder
- Termination of fraudulent policies
- Recovering on any company losses e.g., AOD or legal process
- Reporting fraudulent activities to SAPS, NPA and Regulatory bodies
- Reporting repeat offenders to the Forum
- Attending annual Fraud Awareness workshops
- Sharing of information with other stakeholders to combat crime

Risk Management Skills
- Identify controls in place to establish non-compliance
- Analyzing data and implementing red flags on system
- Random audits on fictitious transactions or claim
- Managing fraud awareness projects for staff and management
- Advertise tip-off anonymous to external community
- Preventing any future losses by developing innovative controls

Auditing Skills
- Identify and misrepresenting documents
- Analyze forged documents
- Analyzing large data for coding abnormalities
- Vast and in-dept knowledge of dental / specialized dentistry
- Establish practice methodologist to prevent any fraud, corruption and theft to prevent any losses
- Request purchase invoices and evaluate claim submitted

Interview Skills
- Question perpetrator to gather relevant information and intention to cause damage
- Present finding and interrogate suspect
- Obtain a statement from perpetrator
- Recover any loss sustained by means of an AOD
- Negotiation skills

Investigating new applicants for non-disclosure of health conditions during the underwriting process
Doing administrative tasks relating to the findings of the investigation
Instituting measures to identify non-disclosure
Confronting member/s and taking necessary action where applicable
Analyzing data to identify possible non-disclosure
Collecting, evaluating and handling of evidence

Liaising with member, service
Providers, brokers etc. Re: unpaid, claims,
Rendering authorizations and dealing with medically related queries
Managing of outpatient and in-patient benefits for members within member’s benefits
Identifying high risk procedures for further
Assessment and management adhering to protocols put in place
Assist in health risk management
Problem solving leading to customers satisfaction
Logged on the queue for a minimum of 6.45hrs a day
All telephones answered according to set standards
Transfer calls only when no further assistance can be rendered
Maintain accurate details of pre-authorization information
Confirm scans according to set protocols
Check validity of membership
Ensure that the reason for admission is appropriate
Requesting BHF/ ICD and CPT and motivation letters on pre- authorization, when necessary
Offer transfers to Smart Health Choice Line for members who need medical information about medical procedures, etc
Follow- up urgent queries
Capture messages on the system
Give authorization numbers for cases that still need to be loaded
Provide product information to all Discovery clients in line with standards and protocols of the call center
Maintain confidentiality