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Team Lead
2 months ago
Job Title: Team Lead - Merits Determination
Job Summary:
The Team Lead - Merits Determination will be responsible for leading the merits determination process, ensuring that claims are thoroughly investigated and verified. This role will involve supervising assessors, generating and comparing calculation results, and handling escalated matters.
Key Responsibilities:
- Merits Management:
- Review and scrutinize claim documentation to ensure accuracy and completeness.
- Ensure that appropriate offers are made to deserving claimants.
- Supervise assessors in the determination of merits.
- Generate and compare different calculation results to ensure accuracy.
- Handle escalated matters and ensure resolution.
- Supervise the determination of liability processes.
- Quality assure merits outcomes and generate offers in line with the Department of Accident (DOA) guidelines.
- Ensure that offers made are submitted to the offer management for further communication to the claimant.
- Approve the appointment of experts to determine liability.
- Provide guidance on the merits process to subordinates.
- Quality Assurance:
- Quality assure information applicable to merits on the accident information center.
- Participate in the consultation process on the implementation of programs and services.
- Ensure that programs and services are implemented and maintained at the highest standards.
- Develop and implement an unusual occurrence procedure.
- Exception Handling:
- Develop additional tracking methods to report analysis results in business case scenarios.
- Develop and maintain a formal exception handling process within the claims process.
- Maintain documentation and regularly update the exception handling process.
- Implement supporting policies and procedures in line with managing exception handling with the division.
- Stakeholder Management:
- Aid in proactive and progressive relationships with key stakeholders.
- Deal with inquiries and requests for information from internal and external stakeholders.
- Aid in maintaining relationships with vendors, service providers, or procurement teams and ensure timely invoicing and payment.
- Reporting:
- Ensure preparation and submission of regulatory reports.
- Report quarterly on progress with implementation of operational plans.
- Develop functional reporting systems, project, or performance reporting for management.
- Develop reports, policies, and procedures and guide the process through alignment with the overall Road Accident Fund (RAF) strategy.
- Prepare and submit regular and periodic reports as required to provide progress updates and inform management decisions.
- People Management:
- Ensure the motivation, cohesiveness, and alignment of the organization's team members.
- Manage staff in the department to ensure they achieve their objectives in line with the strategic objectives of the RAF.
Qualifications and Experience:
- Bachelor's Degree or Advanced Diploma in a Health Sciences or Law-related qualification.
- Relevant 5 years' experience in an insurance or investigations-related environment, with 2 years in operations management.
Technical and Behavioural Competencies Required:
- Claims management process and systems.
- Post-claim management and settlement.
- Medical bill reviewing.
- Medical case management.
- Complex problem identification, solving, and decision-making.
- Customer value proposition.
- Good financial management skills.
- Strong analytical capabilities.
- Knowledge of Motor Vehicle Accident legislation.
- PFMA knowledge.
- Organisational resilience.
- Communication.
- Team orientation.
- Network and alliances.
- Personal mastery.
- Judgment and decision-making.
- Emotional wisdom.
- Ethics and governance.
- Customer orientation and customer focus.
Managerial Competencies:
- Change management.
- Critical and innovative thinking.
- Programme/project management.
- Risk management.
- People management.
- Conflict management.
- Coaching and mentoring.