Claims Assessor

**Job Summary**:
Accurately assess claims Pet Insurance claims submitted for Veterinary facilities. Provide support and education to clients and appropriate vendors/providers relating to claims queries, processes, and the policy. Project a professional company image through omni channel interaction.

**Key Duties & Responsibilities**:

- **Claims Assessing**:
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- Timeous and accurate Assessing of claims (30 claims per day minimum).
- To assist when additional help as needed on queues to keep the live, assist with overflow as directed by team leader and/or supervisor. Queues must be live, this includes tasks met within specified due date.
- Authorization of Hospital (primarily), Day-to-day and/or all related claims as per policy terms and conditions and standard protocol.
- Follow-up on customer/provider enquires not immediately resolved, within determined SLA’s.
- All client communication to be professional and accurate.
- Answer phones and respond to customer requests within the determined SLA.
- Explain products and update customer details in computer system.
- Follow and adhere to claims/company processes, procedures, and protocol.
- Recognize, document, and alert the supervisor of trends in customer calls/claims. And assist in identifying possible/suspected fraudulent claims or clients.
- Recommend process i. changes and/or improvement suggestions
- Focus on first call and/or interaction resolution as far as possible.
- Whatsapp; Answer WhatsApp chats with customer requests within the determined SLA. Accurately and correctly answer all client messages and queries received on the WhatsApp Pet Hospital claims queue. Refer relevant claims queries to the correct pet queue, where relevant.
- Transfer customer calls to appropriate staff, where necessary
- Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim
- Daily updates: Ensure daily stats are manually tracked and updated on the daily spreadsheet and sent to supervisor/ manager at the end of each day. This includes submission of all relevant reports, paperwork and updates on all claims activity as directed, in a timeous manner. Do daily system checks and reporting feedback and any issues to superior/manager timeously.
- Assessing of claims according to standard operating procedure and company protocols
- Improve client service experience, create engaged clients, and facilitate organic growth
- Manages tasks allocated through omni-channel platforms including WhatsApp.
- Handle complex and escalated client service issues.
- Build/maintain rapid channel of communication to client in case of service-related issues and events.
- Represent the “Voice of the Customer”.
- Create a culture of Customer/Client Centricity.
- Identify any potential errors or obstacles that may arise which might impact client experience and ensure this has been addressed and highlighted to Supervisor.
- Demonstrate the Oneplan Values and Culture in all engagements with both clients and internal stakeholders.
- Leverage team success to drive all initiatives and experiences with clients.
- Display leadership through your actions by accepting responsibility for daily deliverables and ensuring turnaround times are achieved.
- Maintain forward thinking and proactiveness by taking ownership of every interaction with the client and managing the client’s queries from end-to-end to ensure a world class client service experience.
- Support cross functional work areas targeted to resolve issues raise.
- **Underwriting**
- Pet image validation
- queue to be cleared daily, and stats on the amount closed to be tracked and reported daily
- Request regularly for updated pet images when working on cases or on a file.
- Claims underwriting queue: Accurately Underwriting of new dependents, Underwriting according to protocol and to ensure effective risk management
- **Additional tasks**
- Be available and willing to assist with any additional tasks and projects, as required by the department.
- Conduct outbound calls as and when required to ensure client is informed and updated on the progress/ status of the claim, and complaint handling.
- **Claims Queries**
- To log every call/ query received / made (Connex/OTRS/Whatsapp/ notes OPA)
- Identify, research, and resolve customer issues using the CRMS.
- Follow-up on customer enquires not immediately resolved, within determined SLA’s.
- Complete call logs and reports.
- Educate clients on claims process and general claims queries.
- **Quality, Consistency and Compliance**
- Maintain standard as per CSAT, QA Call metrics and claim assessing score (85% pass rate) and (3% error rate).
- Timeous answering of chats within specified SLA (5 minutes).
- Deliver quality service by providing efficient, quick, and friendly service to clients within agreed SLA.
- Respond to clients' issues timeously and swiftly, within escalation parameters to ensure consistency.
- Key Performance Area Core