Senior Medical Assessor

3 months ago

Johannesburg, South Africa PPS Recruitment Full time

**Job Advert Summary**:
The role will be responsible for assessing and managing claims with adherence to policy terms and conditions. The successful incumbent will be ccountable for claims processes and procedures and where necessary help with formulating return to work plans or engaging the services of accredited professionals. Assist in improving the process and bring in a level of innovation to ensure an efficient claims process for our members.

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

- Matric (Grade 12)
- Degree in Occupational Therapy or Physiotherapy or equivalent

**Experience**:

- 5 - 6 years’ working experience essential, 4 of which must be in the Life Insurance Industry.
- Assessment of income protection, occupational and functional disability, dread disease and life at a senior level essential.
- Case management experience advantageous with proven track record, preferred.
- Experience in the use of AMA Guides to assess Impairment (Whole person Impairment), essential.
- Knowledge of non-disclosure process and validation preferred.
- Experience in corresponding with clients verbally and in writing.

**Knowledge and Skills**:

- Laws and regulations that govern the long-term insurance industry.
- Formulation of case management programs and plans.
- Good presentation and report writing skills.

**Competencies**:

- Excellent communication skills
- Confident decision making
- Attention to detail and initiative
- Logical and analytical thinking
- Result orientated and deadline driven
- Team player
- Innovative
- Leadership skills
- Persistence and tenacity
- Planning and organising
- Decisiveness
- Process optimisation

**Duties and Responsibilities**:
**Claims Assessment**
- Assess claims across all claim types (Income protection, disability, dread disease and life claims).
- Assess contractual and medical merits of the claims.
- Evaluate claims and determine requirements for future management.
- Prepare communication to members and medical specialists.
- Analyse and summarise medical reports and other information in context of claims and the glu Policy.
- Provide input on future management of all potentially long-term claims, inclusive of potential rehabilitation and return to work programs.
- Keep accurate records of all claims assessed in accordance with departmental procedures.
- Guide and support junior and intermediate assessors.
- Authorise claims in line with the Delegation of Authority.

**Stakeholder Management**
- Correspond and provide regular feedback to clients throughout the claims process.
- Ensure service levels and turnaround times are maintained.
- Liaise with the claims team, legal department, medical team, management and other role players in the claims assessment process.
- Appoint rehabilitation specialist and medical specialist in accordance with a set criterion.

**Complaints and Escalations**
- Accurate analysis and timeous resolution of complaints.
- Prioritisation of escalation and finalisation.
- Identification of trends that result in member/client dissatisfaction and implementing solutions.

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