Senior Claims Assessor
1 month ago
**THE JOB AT A GLANCE**
As the Senior Claims Assessor, you will be reporting to the Team Leader: Senior Claims Assessor. You will be responsible for adjudicating and processing claims in an effective and efficient manner within the prescribed guidelines set out by Rand Mutual Assurance.
**WHAT WILL YOU DO?**
**Adjudicate on claims**:
- Adjudicate claims in line with relevant policies, terms and conditions and all other requirements
- Decide on liability to pay the claims
- Evaluate claims received and determine requirements i.e. medical reports, Statement of Earnings for adjudication
- Evaluate and determine requirements for claims to be presented to RMA Medical staff and Technical Committee for decision making
- Where applicable, refer claims for repudiation
- Identify potential reinsurance and recoveries
- Identify fraudulent and suspicious claims
- Initiate claims investigations and review of investigation reports
- Authorise Permanent Disablement lumpsums and other transaction as per the authority limits policy.
**Manage Claims**:
- Manage claims in line with individual targets
- Review claims in line with processes and limits as set out in RMA guidelines
- Escalate claims out of defined authority limits to Team Leader
- Process claims that fall within defined authority Limits
- Ensure that communication of claims is processed to both employer and employee as set out in the Claim’s Management Processes
- Timeously manage workflows and notifications
- Capture dependents and refer to Team Leader for authorisation where applicable
- Ensure timeous finalisation of claims calculation\authorisation of disability assessments
- Process claims within Maximum Medical Improvement and\or prescribed Claims Processing Cycle.
**Manage Costs**:
- Approve claims for payment within authority limits for Total Temporary Disablement and Permanent Disability lumpsums and where necessary refer to Team Leaders
**Customer Service**:
- Regularly communicate and liaise verbally and in writing with customers/suppliers/visitors/enquirers and relevant staff
- Interpret and respond clearly and effectively to spoken requests over the phone or in person, and to verbal or written instructions
- Manage walk-in queries as and when required
- Provide customers with accurate product and service information in an efficient manner
- Deal with all customers in a professional and empathetic manner
**WHAT WILL YOU GET IN RETURN?**
We offer great opportunities for personal and professional development in a stable company that is 130 years strong. The role comes with a competitive salary package and various benefits. Furthermore, you will be part of a dedicated group of colleagues who value teamwork and collaboration.
**Turnaround time**
**Our Commitment to transformation**:
**WHAT YOU'LL BRING TO THE TABLE?**
- NQF Level 6 Diploma in a FAIS Recognised Qualification
- COIDA in Practice or Insurance Qualification an advantage
- Legal qualification an advantage
- FAIS Regulatory Examination (RE5)
- Minimum 5 years’ experience within the Insurance industry within a claims environment
- Knowledge of payroll admin processes
- Knowledge of COID legislation
- Knowledge of Claims processing, approval and payment processes would be advantageous
- Insurance and/or Medical Aid experience would be advantageous
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