Senior Life Claims Assessor

**JOB PURPOSE**

Process and pay valid life/disability/dread premium waiver claims by reviewing

claims decisions made by life claims assessors; and manage risk by declining

invalid and fraudulent claims.

**RESPONSIBILITIES**

**Claims Data Collection & Analysis**

Ask questions, collect data from a variety of sources, analyse information and

investigate claim. Ensure that the client policy is valid through the appropriate

due diligence (such as listening to the policy sales/retention etc. phone

conversation.

Check claims and validate contracts on claims, that are above claims assessor

limits by reviewing claims decisions made by life claims assessors, by applying

specialist medical assessing skills and knowledge and experience.

assessing skills and knowledge.

Ensure that relevant waiting periods have expired and that all premiums have

been received on the policy.

Audit claim decisions made and processes and procedures followed by life claim

assessors during the assessment process.

Ensure that the correct decision is made with regards to acceptance/declining

payment of claim based on appropriate documents received and relevant

contract in place.

**Correspondence**

Ensure that a claimant is kept informed at all times with regards to their claim

process. To ensure that the appropriate settlement documentation is sent to the

appropriate parties outlining the amounts paid and the reasons for it; and ensure

that the relevant parties for a declined claim are contacted and the reasons for

the claim being declined is explained thoroughly.

Ensure that relevant claims correspondence is forwarded to the reinsurer.

**Customer Management (Internal and External)**

Help manage customers by carrying out activities to complete the customer

request. Provide feedback to the complaints department on customer complaints

and queries regarding outcome of claims decision.

Adhere to SLAs between claims and the complaints department and providing

the complaints department with comprehensive feedback on the background of

the claim and decision made.

Comply with current claims policy and procedures and ensure that production

targets are met and that relevant turnaround times and SLA's are adhered to.

To appropriately escalate any red flags / discrepancies to the relevant

department (for example forensics) as and when identified.

**Administration**

To ensure that the correct banking details are received and captured and that the

correct amount in terms of an accepted claim is paid to the appropriate parties.

Ensure that all appropriate documents are in place relating to a client policy and

ensure that the appropriate disclosures were made by the life assured.

Ensure claims statistics are updated correctly and timeously and that all internal

and external communication regarding the claim is stored on the relevant folder.

**Continuous Improvement**

Leverage all available information from our partners, the industry, and internally

to ensure we are constantly reviewing our departmental processes, systems and

protocols with a view to improve efficiencies. Analyse current performance

inhibitors and finding solutions to ensure business continuity.

**Personal Capability Building**

Develop own capabilities by participating in assessment and development

planning activities as well as formal and informal training and coaching. Develop

and maintain an understanding of relevant technology, external regulation, and

industry best practices through ongoing education, attending conferences, and

reading specialist media.

**Performance Management**

Prioritise own workflow and ensure work is completed to the required standards

of productivity, quality and timeliness.

Monitor the performance of the team; allocate work and review completion, take

appropriate corrective action to ensure timeliness and quality. Ensure that

production targets are met and that relevant turnaround times and SLAs are

adhered to.

**Organisational Capability Building**

Provide instruction and informal advice to less experienced colleagues within the

team to develop their skills.

**EDUCATION**

**General Education**
- Grade 12/ SAQA Accredited Equivalent (Essential)
- Recognized FSCA qualification (Essential)
- Regulatory exam 5 (Essential); Nursing/relevant medical qualification (Advantageous)
- Class of Business Certification (Advantageous)

**EXPERIENCE**

**General Experience**
- 4 or more years claims assessing experience in the life insurance industry
- (Essential); Experience in a medical environment (Advantageous)

**Managerial Experience**
- Experience of general supervision of more junior colleagues (Advantageous)

**ADDITIONAL INFORMATION