Senior Pi Claims Assessor

2 weeks ago

Johannesburg, South Africa PPS Recruitment Full time

**Job Advert Summary**:
This role reports to the Team Manager Claims. Responsible for assessment and management of long-term Sickness, Permanent Incapacity and Disability claims. The role will transfer specialist claims knowledge, in-depth process knowledge and client centric principles. The incumbent will deal with technical and complex claims queries and/or complaints providing an excellent service offering. A close relationship with Research & Development to support interdepartmental and wider organizational goals.

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

- Degree in Occupational Therapy or Physiotherapy

**Experience**:

- 5+ years’ experience in the insurance industry.
- 4+ years’ experience in claims assessment including Income protection, Lump Sum.
- Disability and dread disease.
- Case Management experience is an advantage.

**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**:

- Assessment and management of long-term Sickness, Permanent Incapacity and Disability 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.
- Present the claims at Medical Officers Committee for assessment.
- Prepare detailed referral letters to independent specialists and detailed decision letters to members.
- Manage long-term claims by facilitating potential rehabilitation and return to work programs with appointed specialists.
- Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
- Conduct member visits or member meetings when required.
- 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 service-owning 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 and management 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**:

- Empower team members with transfer of knowledge, be the Operations 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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