Key Purpose

• To ensure that the claims service strategy prevails in that adherence of the assessment of claims decisions are proved to the relevant stakeholders, in keeping with the business rules, set criteria and service level agreement discipline.

Areas of responsibility may include but not limited to

• Effective independent assessment of complex claims within high authority limit and skill level to ensure accuracy of decision-making identifying material non-disclosure, misrepresentation or fraud.
• Demonstrate proficient service through formal communication to ensure adherence to communication standards. Building relationships with brokers and franchises, engages with top Premium platinum and Gold Prestige financial advisors to ensure successful execution of claims deliverables.
• Adherence to service level agreement discipline to ensure service standard.
• Attain a quality assurance of above 85% to ensure effective claims decision making and communication output.
• Coach and conduct training for junior or new assessing staff to ensure skills transfer and accurate decision making.
• Presents individual claims on disputes, declines, voids and reconstructs to various committees including medical, legal, underwriting, actuarial and compliance for verification.

Competencies & Skills

• Decision making skills
• Analytical skills
• Effective communication skills
• Attention to detail

Qualifications & Experience

Essential:

• Matric
• Diploma/ Bachelor’s degree in health-related field (such as nursing, occupational therapy, psychology, physiotherapy, etc.
• 4-5 years of working experience in claims assessment of all types of benefits e.g. Life cover, disability, severe illness and income protection claims in the long-term insurance industry.

Advantageous:

• 2-5 years underwriting experience in a long terms insurance industry
• Risk management knowledge with experience of Individual Life claims assessment of all benefits.
• Medical knowledge in terms of terminology and interpretation of medical reports.