Operational Manager: Claims

6 months ago

Johannesburg, South Africa PPS Recruitment Full time

**Job Advert Summary**:
This is a senior position reporting to the CFO. This role will oversee the claims department responsible for the assessment and processing of Death, Sickness, Critical Illness and Hospital claims. If you have extensive experience in claims assessment in a life company, self-driven, confident to handle complex claims issues, possess good communication skills, ability to coach & develop and stakeholder management (claims staff, Research &Development, Intermediaries and the Sales team), this position could be yours

**Minimum Requirements**:
**Education**:

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

**Experience**:

- 6+ years’ experience in the insurance industry.
- 4+ years’ experience in claims assessment including Life, Income protection, Lump Sum Disability, and dread disease.

**Knowledge and Skills**:

- 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 team-player 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**:

- Determine policy terms in line with claims policy and risk assessment.
- Coaches and mentors’ staff within the claims team.
- Expertly applies all applicable guidelines when assessing claims decisions with a higher level of authority.
- Management of Life, sickness, critical illness and hospital claims processes and workflow allocation within the claims department.
- Technical guidance for claims - Inclusive of potential non-disclosure, and exclusions.
- Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
- Deal with escalated queries by members and brokers.
- Deal with Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
- Attend Sales roadshows and Risk Seminars to provide technical and claims support.

**Risk and Compliance**:

- Define and drive adherence 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, Non-disclosure 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.

**Knowledge Champion**:

- Provide guidance and support to junior claims assessors.
- Empower team members with transfer of knowledge, be the Claims Team SME.
- Ensure that own knowledge is kept abreast with industry & regulatory information and changes through various internal and external information sources.
- Provide technical information and support.

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