Life Claims Assessor

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.

Medically assess the validity of the claim by applying specialist medical

assessing skills and knowledge.

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

been received on the policy.

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

Help manage customer by carrying out standard activities to complete the

customer request. Provide feedback to the complaints department on customer

complaints and queries regarding outcome of claims decision.

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. Analyze 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.

TECHNICAL

Data Collection and analysis

Provide technical guidance when required to analyze data to help guide decision

making on the claims.

Medical knowledge

Apply concepts of knowledge / skill and able to provide technical guidance when

required.

Basic Medical Industry knowledge.; Knowledge of Human Anatomy..

Customer Service Delivery

Provide technical guidance as needed on meeting high customer service

standards.

Verbal and Written Communication

Use clear and effective verbal and written communication skills and provides

technical guidance when required to express ideas, request actions and

formulate plans or policies.

Policy and procedures

Monitor, interpret and understand policies and procedures, while making sure

they match organizational strategies and objectives.

Knowledge of Life Insurance Principles.

Policy and Regulation

Interpret and apply knowledge of laws, regulations and policies in area of

expertise.

Basic legal contract principles.

Numerical Skills

Use an understanding of numerical concepts to perform mathematical

operations to calculate claims.

Calculation of claims.

Computer and system skills

Support business processes by understanding and effectively using standard

office equipment and in house and standard software packages.

Basic computer skills.; Proficient in MS Office..

Planning and Organizing

Plan, organize, prioritize and oversee activities to efficiently meet business objectives.

Action Planning

Develop appropriate plans or perform necessary actions based on

recommendations and requirements.

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

2 or more years claims assessing experience in the life insurance industry

(Essential); Experience in a medical environment (Advantageous)

ADDITIONAL INFORMATION

*SAQA Accredited Equivalent - it is the onus of the applicant to provide 1Life and its subsidiaries with certified evidence that their qualification(s) meet the equivalent NQF level required for this role at time of application. *Financial Sector Conduct Authority (FSCA) competency requirements: FAIS recognised qualifications / Regulatory Examinations / Class of Business Certification and / or CPD according to your DOFA (where applicable). As a registered Financial Service Provider, we are mandated to ensure that all our representatives are and remain fit and proper at all times. By applying for this role, you consent to having your relevant qualification and or accreditation or confirm that you are working towards meeting the competency requirements. You further consent to the relevant information being verified