Senior Claims Assessor

11 hours ago


Johannesburg, South Africa PPS Recruitment Full time

**Job Advert Summary**:
**Purpose of the Job**:
This role reports to the Team Manager: Claims and is responsible for assessing and processing short-term Sickness, Critical Illness and Hospital claims. The incumbent will deal with technical and complex claims queries and/or complaints providing an excellent service offering.

A close relationship with Research & Development is required to support interdepartmental and wider organisational goals.

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

- Matric (Grade 12)
- Medical qualification compulsory (Nursing, Occupational Therapy and Physiotherapy or related)

**Experience**:

- 6+ years of experience in the insurance industry
- 4+ years of experience in claims assessment including income protection, lump sum disability and dread disease

**Knowledge and Skills**:

- Fluent in English, both written and verbal communication
- 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 the ability to work under pressure
- Logical and analytical
- Effective time management skills

**Competencies**:

- Communication skills (written and verbal)
- Business writing skills
- Planning and organising
- Attention to detail
- Client centricity
- Building and maintaining relationships
- Resilience
- Stakeholder engagement
- Analytical and critical thinking

As a responsible employer, PPS encourages you to vaccinate and take the recommended vaccine boosters.

The Company reserves the right to amend this stance, as and when required.

**Duties and Responsibilities**:
Process optimisation and efficiencies:

- Assessment and management of short-term sickness, critical illness and hospital claims
- Check the technical aspects of the claim, inclusive of potential non-disclosures and exclusions
- Review all medical information on file, and analyse and synopsise the information at hand
- Determine and record additional required information
- Decide on referrals to an independent specialist
- Receive Independent Specialist reports and analyse and synopsise the report in the context of the claim and PPS Provider Policy
- Correspondence to clients concerning claims outcomes and requirements for future claims to manage claims
- Keeping accurate records of all claims assessed in line with departmental procedures
- Deal with Arbitration and Ombudsman cases and collaborate with other stakeholders 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 SLAs 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 authorisation 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
- 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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