Minimum Requirements
Education:
Medical qualification compulsory (Nursing, Occupational Therapy and Physiotherapy or related).
Experience:
4 years’ experience in the insurance industry.
3 years’ experience in claims assessment including Income protection, Lump Sum Disability and dread disease.
Proven work experience as Claims Assessor in customer-facing role.
Knowledge and Skills:
Must have excellent telephone etiquette.
Good computer knowledge – MS Outlook, Excel and Word are necessary.
Good report writing and presentation skills.
Must have a mature, disciplined and driven personality.
Ability to work independently as well as being a good team-player with excellent interpersonal skills.
Attention to detail.
Deadline/target driven, with ability to work under pressure.
Logical and analytical.
Effective time management skills.
Competencies:
Communication skills (written and verbal).
Business writing skills.
Planning and organizing.
Attention to detail.
Client centricity.
Building and maintaining relationships.
Resilience.
Duties and Responsibilities
Process optimization and efficiencies:
Assessment and management of short-term sickness, critical illness and hospital claims.
Check the technical aspects of the claim – Inclusive of potential non-disclosure, and exclusions.
Review all medical information on file, analyze and synopsize information at hand.
Determine and record additional required information.
Decide on referral to an independent specialist.
Receive Independent Specialist reports and analyze and synopsize the report in context of the claim and PPS Provider Policy.
Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
Keeping accurate records of all claims assessed in accordance with departmental procedures.
Deal with first line queries by members and brokers telephonically and via e-mail.
Deal with Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
Participation in projects to improve departmental service-owning your role in the project and completing tasks as required by providing input.
Risk and Compliance:
Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards.
Proficient in the assessment of claims.
Must understand claims environment and general claims protocols and processes.
Ensure adherence to audit requirements.
Ensure adherence to regulatory and compliance requirements.
People and Culture:
Checking and Authorization of claims in terms of published delegation of authority.
Collaboration with relevant stakeholders: Research & Development, Legal, Operational Accounts, Non-disclosure and Internal Control.
Contribute and assist to review processes and protocols where required to assist in PPS’ delivery of quality claims decisions.
Forge strong working relationships with stakeholders.
Knowledge Champion:
Ensure that own knowledge is kept abreast with industry & regulatory information and changes through various internal and external information sources.
Provide technical information and support.
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