Senior Pi Claims Assessor

4 hours ago

Cape Town, South Africa PPS Group Full time

**Main duties and responsibilities**:
Process optimisation 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
- Participate 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 service level agreements (SLAs) 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 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:

- 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

**Education**:

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

**Experience**:

- 6+ 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**:

- Must have excellent telephone etiquette
- Good computer knowledge - MS Outlook, Excel and Word are necessary
- 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
- Logical and analytical
- Deadline/target driven, with ability to work under pressure
- Good report writing and presentation skills
- Business writing skills

**Competencies**:

- Planning and organising
- Attention to detail
- Client centricity
- Building and maintaining relationships
- Resilience

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