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Risk Adjustment Specialist

1 month ago

Sandton, South Africa Neptune Full time

About Neptune

We are a dynamic and innovative company dedicated to delivering exceptional service to our customers.

Job Summary

We are seeking a highly skilled Risk Adjustment Specialist to join our team. As a key member of our Insure, Alternative Risk Transfer team, you will be responsible for managing and processing all claims assigned, including legal requirements and industry regulations.

Key Responsibilities:

  • Claims Processing: Manage and process all claims assigned, adhering to set standards and contributing to the productivity of the division.
  • Rejection Management: Manage rejections, cancellations, and over-claims mandates for Cell Captive/binder arrangements.
  • Customer Service: Enhance the image of the company through the continuous delivery of efficient and effective customer service.
  • Claims Authorization: Authorize all claims above the binder's set mandates.
  • Turnaround Time Management: Ensure all claims within the designated portfolio are effectively and timeously processed within stipulated turnaround times.
  • Loss Adjusting Activities: Get involved in loss adjusting activities and legal discussions relating to settlement.
  • Claims Reports: Manage claims reports from binder holders.
  • Procurement Procedures: Ensure adherence to Hollard Procurement procedures.
  • Claims Service Levels: Provision and adherence to claims service levels.
  • Policy Terms and Conditions: Interpretation and application of policy terms and conditions ensuring all validation checks.
  • Fraud Detection and Management: Detection and management of fraud, dishonesty, misrepresentation.
  • Rejection Handling: Handling rejections, ensuring fairness and diplomatic communication.
  • Complaints Handling: Handling any complaints associated with claims.
  • Business and Scheme Rules: Ensure application of business and scheme rules.
  • Servicing Principles: Ensure the servicing principles of Hollard are always adhered to.
  • Policy Wording Interpretation: Manage the correct, consistent interpretation and application of the policy wording and ensure that all claims are treated equitably.
  • Performance Management: Day-to-day self-management of performance.
  • Valid Claims Settlement: Ensure appropriate controls are in place for valid claims settlement.
  • Ad-Hoc Projects: Participate in ad-hoc projects as required.
  • Binder Holder Communication: Ensure accurate and timeous response to binder holders on queries.
  • Monthly Reporting: Provide monthly reports and communication to team leader/management.
  • Junior Staff Guidance: Provide guidance to more junior staff on complicated or high-value claims.
  • Third-Party Recoveries: Deal with third-party and third-party recoveries.
  • Claims Reviews: Participate in claims reviews at binder holders.
  • Binder Meetings: Attend binder meetings/reviews.

Salary Range: R400,000 - R600,000 per annum (dependent on experience)