Intermediate Sickness Claims Assessor

2 weeks ago


Johannesburg, Gauteng, South Africa PPS Recruitment Full time

Job Advert Summary:

This role reports to the Team Manager Claims. Responsible for assessment and processing of short-term Sickness, Critical Illness and Hospital claims. The incumbent will deal with technical and complex claims queries and/or complaints providing an excellent service offering.

Minimum Requirements:

Education:

  • Medical qualification compulsory (Nursing, Occupational Therapy and Physiotherapy or related)

Experience:

  • 3 years' experience in the insurance industry
  • 2 years' experience in claims assessment including Income protection, Lump Sum, Disability and dread disease

Knowledge and Skills (maximum of 10):

  • Fluent in English both written and verbal
  • 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 teamplayer 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 shortterm 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 Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
  • Participation in projects to improve departmental serviceowning 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, Nondisclosure 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


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