Claims Assessor

4 days ago

Sandton, South Africa Oneplan Underwriting Managers (Pty) Ltd. Full time

**Main purpose of the job**

Accurately assess claims. Provide support and education to clients and appropriate vendors/providers relating to claims queries, processes, and the policy. Project a professional company image through omni channel interaction.

**Claims Assessing**
- Timeous and accurate Assessing of claims (30 claims per day minimum). Queues must be live.
- Authorization of Hospital (primarily), Day-to-day and/or all related claims as per policy terms and conditions and standard protocol.
- Answer phones and respond to customer requests within the determined SLA.
- Explain products and update customer details in computer system.
- Follow and adhere to claims/company processes, procedures, and protocol.
- Recognize, document, and alert the supervisor of trends in customer calls/claims.
- Recommend process improvements.
- Focus on first call resolution as far as possible.
- WhatsApp; Answer WhatsApp chats with customer requests within the determined SLA. Accurately and correctly answer all client messages and queries received on the WhatsApp Pet Hospital claims queue. Refer relevant claims queries to the correct pet queue, where relevant.
- Transfer customer calls to appropriate staff, where necessary
- Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim
- Daily updates: Ensure daily stats are updated and sent to supervisor/ manager at the end of each day. This includes ssubmission of all relevant reports, paperwork and updates on all claims activity as directed, in a timeous manner.
- Assessing of claims according to standard operating procedure and company protocols
- Improve client service experience, create engaged clients, and facilitate organic growth
- Manages tasks allocated through omni-channel platforms including WhatsApp.
- Handle complex and escalated client service issues
- Build/maintain rapid channel of communication to client in case of service-related issues and events
- Represent the “Voice of the Customer”
- Create a culture of Customer/Client Centricity
- Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Supervisor.
- Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
- Leverage team success to drive all initiatives and experiences with clients.
- Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
- Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client’s queries from end-to-end to ensure a world class client service experience.
- Support cross functional work areas targeted to resolve issues raised by clients.
- Proactively gather client feedback to optimize client experience

**Underwriting**
- Pet image validation
- queue to be cleared daily, and stats on the amount closed to be tracked and reported daily
- OTRS Claims underwriting queue: Accurately Underwriting of new dependents, underwriting according to protocol and to ensure effective risk management

**Additional tasks**
- Be available and willing to assist with any additional tasks and projects, as required by the department.

**Claims Queries**
- To log every call/ query received / made (OTRS/WhatsApp/ notes OPA)
- Identify, research, and resolve customer issues using the CRMS.
- Follow-up on customer enquires not immediately resolved, within determined SLA’s.
- Complete call logs and reports.
- Educate clients on claims process.

**Quality, Consistency and Compliance**
- Maintain standard as per CSAT, QA Call metrics and claim assessing score (85% pass rate) and (3% error rate).
- Timeous answering of chats within specified SLA (5 minutes)
- Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
- Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency
- Ensure adherence to standard operating procedures and demonstrate exceptional product knowledge in client engagements.
- Ensure quality assurance standards are met as per company guidelines.
- Ensure adherence to all relevant legislation and regulations as set out by the Company, Regulatory Board, and the Financial Services industry.

**Work collaboratively**
- Build a culture of respect and understanding across the organisation
- Recognise outcomes which resulted from effective collaboration between teams
- Build cooperation and overcome barriers to information sharing, communication, and collaboration across the organization
- Facilitate opportunities to engage and collaborate with internal and external stakeholders to develop joint solutions

**Self-Management**
- Follow through to ensure that personal quality and productivity standards are consistently and accurately maintained
- Plan and

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