Claims Auditor

3 weeks ago

Centurion, South Africa Land Bank Careers Full time

**Job Advert Summary**:
To conduct regular audits which includes planning, implementation and reporting on audits for the various product lines as well administering the life insurance claims which includes, registering, assessing, negotiating and settlement of claims within LBIC and LBLIC.**
Key Performance Areas**:
1. Claims Auditing (LBIC and LBLIC) - Audit Planning - audit scoping, sample preparation on working papers and conducting opening meetings, audit planning memorandum - Implementation - testing scoped work and challenge control design and effectiveness, keep evidence and manage time accordingly - Assists with the maintenance of a quality assurance and improvement program that covers all aspects of the internal audit function (at an engagement level), and continuously monitor its effectiveness - Manage SLA’s with third parties insofar as claims management in concerned Perform claims data analysis to identify non-compliance with SLA’s - Follow-up on claims paid and determine client experience - Verbally communicates findings to management at functional level and drafts comprehensive issue summary of audit area. - Obtains provisional management comments at functional level. - Ensures all audit and compliance reports are provided timeously, accurately and in line with requirements. - Gives input into the management and control of the departmental operational plans and budget. - Ensures detailed accurate recordkeeping of records. - Analyses routine information for reporting purposes to the Senior Internal Auditor on the completion of an audit - Performs system descriptions documentation, risk and control identification and assists in the development of the detailed audit planning memorandums and Risk and Control Matrix (RACMs). - Prepares risk based audit programs and procedures. - Evaluates the adequacy and operating effectiveness of internal control designs. - Executes allocated internal audit assignments. 2. Life Claims Administration - Technical assessment of claim by checking the applicable cover, scheme and member details, eligibility, financial details - Assess and confirm the eligibility, authenticity and validity of all evidence submitted by clients - Acknowledge all information received and let the client know who the assessor is - Request additional information and explain why the information is still required If there is no medical information shared in any evidence or forms submitted - Assess and confirm the eligibility, authenticity and validity of Certificates of Existence Claims and all claims notifications - Assure capturing of claims are done accurately - Assure all criteria is met to pay claim - Calculating benefits payable - Maintain and update the claims register - Maintains, arrange, organize and update the filing systems and procedures - Compilation of statistics - Capturing new and existing (admitted, invalid and pended) claims on LBIC register - Sending out reminder letters on due dates for all pending claims and existing claims that are undergoing reviews - Responding to queries and ensuring that all queries are dealt with professionally, effectively and stipulated turn-around times are met 3. Underwriting Managers Association’s Claims Assessment - Claims assessing and validation including settlement, rejection and repair within set SLA - Loss adjustment by correctly quantifying losses - Mediation; serve as mediator between Insure and client - Reporting on all claims handles - Analyse client behaviour to determine legitimacy of claims - Investigate and report on fraudulent claims 4. Claims Quality Assurance - Provides input into the development or changing of operations policies or drafting of new policies and/or claims control systems on request. - Consults existing control systems to determine components that can be utilised/amended in the required control system. - Develops the first draft of the control system in accordance with company format and requirements. - Communicates the implementation of the control system in accordance with policies and procedures. - Implements control systems in accordance with policies, procedures and legal requirements.**
Preferred Minimum Education and Experience**:

- Commercial Degree (BCom/ Business Management/ Economics/ Law/ Risk Management) - 3-5 years experience in short term and/or Life insurance claims negotiation and handling - 3-5 years experience in short term and/or Life general insurance - 3-5 years experience in claims handling and Auditing - 3-5 years claims auditing experience of SLA partners, UMA’s and Binder Holders**
Critical Competencies**:

- Short term and/or life insurance claims negotiation and handling on an insurance operating system - Claims auditing of SLA partners, UMA’s and Binder Holders - General short term and/or life insurance experience - Claims function Quality assurance - Microsoft Office**
Additional Requirements**:

- Travel as and when required - Extended hours as and when required.

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