Senior Claims Assessor

1 day ago

Johannesburg, South Africa PPS Recruitment Full time

**Job Advert Summary**:
Responsible for the assessment and management of long-term Sickness, Permanent Incapacity, and Disability claims. The incumbent applies specialist claims expertise, deep process knowledge, and a client-centric approach to deliver high-quality service. The role involves handling complex and technical claims queries and complaints, ensuring superior service experience. Collaboration with the Research & Development team is essential to support cross-functional and broader organisational objectives.

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

- Degree in Occupational Therapy/Physiotherapy or any relevant clinical qualification

**Experience**:

- 5+ years’ experience in the insurance industry
- 4+ years’ experience in claims assessment including Income protection, Lump Sum Disability and dread disease
- Case Management experience (preferred)

**Knowledge and Skills**:

- Must have excellent telephone etiquette
- Good computer knowledge - MS Outlook, Excel and Word are necessary
- Ability to work independently as well as being a good team-player with excellent interpersonal skills
- Logical and analytical
- Effective time management skills
- Deadline/target driven, with ability to work under pressure
- Logical and analytical
- Excellent report writing and presentation skills

**Competencies**:

- Planning and organizing
- Attention to detail
- Client centricity
- Building and maintaining relationships
- Resilience
- Complex problem solving
- Adapting and responding to change
- Innovation and Forward Thinking

**Duties and Responsibilities**:

- Assess and manage long-term Sickness, Permanent Incapacity, and Disability claims in line with policy and procedural guidelines
- Review, analyse, and summarise medical documentation to support informed decision-making
- Evaluate technical aspects of claims, including potential non-disclosure and applicable exclusions
- Present complex claims to the Medical Officers Committee for further assessment and decision-making
- Draft comprehensive referral letters to independent specialists and detailed decision letters to members
- Manage long-term claims by coordinating rehabilitation and return-to-work programs in collaboration with appointed specialists
- Communicate claims outcomes and future claim requirements to members, ensuring clarity and transparency
- Manage Arbitration and Ombudsman cases, working closely with relevant stakeholders throughout the complaints process
- Demonstrate consistent adherence to audit requirements to support compliance and governance standards
- Serve as a Subject Matter Expert (SME) by sharing specialist knowledge and providing technical guidance to colleagues and stakeholders

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