Claims Assessor: Life

2 weeks ago

Durban, KwaZulu-Natal, South Africa Datafin Full time

ENVIRONMENT:
A highly meticulous & solutions-driven

Claims Assessor:
Life is sought by a dynamic provider of cutting-edge and economical business solutions, headquartered in KwaZulu-Natal.

Your core role will be to validate, evaluate, make the correct assessment decision, and calculate the correct settlement for CPP (Life) Claims assessed.

You will check the status of the policy and receipt of premium (current and up to date), to facilitate claim processing, work through negative deferred days and possible prescription while providing excellent service to policy holders and business partners in respect of Claims.

Applicants will need Grade 12/Matric, a relevant NQF 4, preferably a Further Education and Training Certificate (FETC) in Short Term Insurance, Long Term Insurance or Retail Insurance & FAIS Regulatory Exam for Representatives (RE5).

You must have 2-4 years' work experience as a Life Assessor is required with detailed knowledge relating to the specialist/technical nature of life claims assessment & a solid understanding of medical conditions and the ability to understand medical terminology and medical reports.


DUTIES:
Claims Processing
  • Confirm that the claim intimation is correct and valid.
Check the status of the policy and receipt of premium (current and up to date), to facilitate claim processing. Responsible for ensuring that all the required supporting documentation is obtained to comprehensively assess the claim. If necessary, requesting the Claims Administrator to source outstanding documents. Responsible for evaluating and assessing the claim as per the policy wording/requirements documented in the policy wording. Responsible for updating in-house systems with relevant information and developments throughout the assessment process. Responsible for making the "correct" decision in respect of the claim. Responsible to facilitate the process of claim settlement.

Responsible for ensuring the accuracy and completeness of system data relating to the claim to facilitate the accuracy of system generated claim settlement amounts.

Responsible for achieving daily performance targets. Responsible for calculating the correct claim amount payable. Administrative Duties
  • Support all involved stakeholders with regard to claim queries.
Ensure that all interactions and developments are well documented on in-house systems. Ensure optimal use of MOS to manage workload. Responsible for generating payment requisitions to facilitate claim payments. Assume overall responsibility for the content of the decision notification sent out to all relevant parties. Work on the queries on the Assessor 1 queue. Attend to ad hoc business partner queries. Attend to complaints received from the Complaints Department and walk-in clients. Work through negative deferred days and possible prescription. Work outbound call on vehicle claims in excess of 100 days old (will be allocated by Manager). Attend to email correspondence received from clients, business partners and internal. Ad hoc related administration related to claims. Customer Service
  • Ensure that the principles of TCF are embodied in the assessment process/decision.
Provide excellent service to policy holders and business partners in respect of Claims. Responsible for providing supportive input to Customer Experience with regard to customer complaints. Liaise with policy holders regarding the status of their claim and keep them informed if necessary. Responsible for maintaining the service level standards agreed with business partners as per the SLAs.

REQUIREMENTS:
Qualifications – Matric / Grade 12.

Minimum qualification:
Relevant NQF 4. A medical qualification would be an advantage

Preferred qualification:
Further Education and Training Certificate (FETC) in Short Term Insurance, Long Term Insurance or Retail Insurance. FAIS Regulatory Exam for Representatives (RE5). Experience/Skills – At least - 4 years' work experience as a Life Assessor is required. Previous work experience in long term insurance services, financial services or an insurance company would be most valuable. Relevant technical knowledge to understand the technical requirements of life assessment is required. A good understanding of general financial concepts is required. Good understanding of the claims assessment process. Detailed knowledge relating to the specialist/technical nature of life claims assessment. Good understanding of medical conditions and the ability to understand medical terminology and medical reports.

Logical and analytical and able to make accurate, complete deductions from multiple sources of information received in respect of the claim.

Knowledge of the relevant policies and the ability to understand and interpret relevant policy wordings. Able to make correct and timely decisions as informed by policy wordings. MS Office Skills including Excel. Ability to apply judgement and tact when providing explanations. Able to manage policy holder expectations. Ability to interpret medical reports.

ATTRIBUTES:
Good communication skills, both written and verbal. High levels of attention to detail to ensure accuracy and completeness. Ability to work independently and demonstrate initiative. Team orientation. Committed to team goals, targets and objectives. Good organisational and time management skills. Able to plan and prioritise in order to meet deadlines. Results focused. Quality orientation. Customer Service orientation. Integrity. Empathetic, patient and tolerant. Diplomatic and mindful of impact. Cross cultural awareness. Assertive and confident.
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