RESPONSIBILITIES

Claims Data Collection & Analysis

• Ask questions, collect data from a variety of sources, analyse information and investigate claim. Ensure that the client policy is valid through the appropriate due diligence (such as listening to the policy sales/retention etc. phone conversation.
• Medically assess the validity of the claim by applying specialist medical assessing skills and knowledge.
• Ensure that relevant waiting periods have expired and that all premiums have been received on the policy.
• Ensure that the correct decision is made with regards to acceptance/declining payment of claim based on appropriate documents received and relevant contract in place.

Correspondence

• Ensure that a claimant is kept always informed with regards to their claim process. To ensure that the appropriate settlement documentation is sent to the appropriate parties outlining the amounts paid and the reasons for it; and ensure that the relevant parties for a declined claim are contacted and the reasons for the claim being declined is explained thoroughly.
• Ensure that relevant claims correspondence is forwarded to the reinsurer.

Customer Management

• Help manage customer by carrying out standard activities to complete the customer request. Provide feedback to the complaints department on customer complaints and queries regarding outcome of claims decision.
• Comply with current claims policy and procedures and ensure that production targets are met and that relevant turnaround times and SLA’s are adhered to.
• To appropriately escalate any red flags / discrepancies to the relevant department (for example forensics) as and when identified.

Administration

• To ensure that the correct banking details are received and captured and that the correct amount in terms of an accepted claim is paid to the appropriate parties.
• Ensure that all appropriate documents are in place relating to a client policy and ensure that the appropriate disclosures were made by the life assured.
• Ensure claims statistics are updated correctly and timeously and that all internal and external communication regarding the claim is stored on the relevant folder.

Continuous Improvement

• Leverage all available information from our partners, the industry, and internally to ensure we are constantly reviewing our departmental processes, systems and protocols with a view to improve efficiencies. Analyse current performance inhibitors and finding solutions to ensure business continuity.

Personal Capability Building

• Develop own capabilities by participating in assessment and development planning activities as well as formal and informal training and coaching. Develop and maintain an understanding of relevant technology, external regulation, and industry best practices through ongoing education, attending conferences, and reading specialist media.

EDUCATION

General Education

• Grade 12/ SAQA Accredited Equivalent (Essential)
• Recognized FSCA qualification (Essential)
• Regulatory exam 5 (Essential)
•  Nursing/relevant medical qualification (Advantageous
•  Class of Business Certification (Advantageous)

EXPERIENCE

General Experience

• 2 or more years claims assessing experience in the life insurance industry (Essential)
• Experience in a medical environment (Advantageous)