Senior Claims Assessor

3 months ago


Parktown, South Africa PPS Recruitment Full time

**Job Advert Summary**:
This role reports to the Team Manager Claims. Responsible for assessment and processing of short-term Sickness, Critical Illness and death claims. Quality assurance and authorization of claims for Junior and Intermediate claims assessors. Facilitate complex claims discussions within the team, conduct training and coaching to the team and do claims presentations when required. Assist team manager with daily queue management and reporting. The incumbent will deal with technical and complex claims queries and/or complaints providing an excellent service offering.

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

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

**Experience**:

- 5 years’ experience in the insurance industry.
- 3 years’ experience in claims assessment including 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**:

- Assessment and management of short-term sickness, critical illness and death claims.
- Quality assurance and authorization of claims for Junior and Intermediate claims assessors.
- Facilitate complex claims discussions within the team, conduct training and coaching to the team and do claims presentations when required.
- Assist team manager with daily queue management and reporting.
- 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.
- Keeping accurate records of all claims assessed in accordance with departmental procedures.
- Deal with deal with technical and complex claims queries and/or complaints providing an excellent service offering.
- 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.
- Facilitate and contribute to claims process improvements.

**Risk and Compliance**:

- Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards.
- Proficient in the assessment and quality assurance 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.



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