Senior PI Claims Assessor

6 days ago

Johannesburg, Gauteng, 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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