Assess, review and manage living benefit claims in accordance with relevant legislation and company policy, adhering to service level agreements and meeting client and business expectations.
Requirements
- Grade 12 or equivalent qualification.
- Minimum of 1-2 years experience in processing claims.
- Experience in the assessing of relevant insurance or medical aid claims, paper and/or EDI (required).
- Analytical skills.
- Attention to detail.
- Interpersonal skills.
- Problem solving skills.
- Knowledge of relevant legislation and industry regulations.
- Knowledge of the claims assessment process (paper and EDI).
- Knowledge of the relevant scheme or product rules.
- Knowledge of relevant claims operating systems and tools.
- Assess, review and manage disability, dread disease and income disability claims and any other claims that need a medical assessment component in line with service level agreements.
- Partner and collaborate with relevant stakeholders, to improve claims assessment and the clients claim experience.
- Advise on and contribute to the development of procedures and processes within area of specialisation for continued quality and service improvement.
- Keep accurate records of all claims assessed in accordance with business expectations and relevant legislation.
- Keep abreast of relevant regulatory frameworks, insurance related court decisions and/or determinations by regulatory bodies, governing bodies etc. that could impact the way claims are processed or handled.
- Assist with continuous improvement efforts through the identification of opportunities, cost reduction, improvement on the quality of claims decisions and systems enhancement.
- Provide insight, knowledge, assistance and testing support where necessary as part of the development and maintenance of claims systems to improve quality and efficiency.
- Give input into and review claims policies, practices, forms and documentation to ensure that risk management standards are met and aligned to relevant product changes and legislative updates.
- Provide accurate and timeous reporting, analysis and insights on claims assessed as and when required.
- Provide authoritative expertise to clients and stakeholders.
- Build and maintain relationships with clients and internal and external stakeholders.
- Deliver on service level agreements made with clients and internal and external stakeholders in order to ensure that client expectations are managed.
- Make recommendations to improve client service and fair treatment of clients within area of responsibility.
- Participate and contribute to a culture which builds rewarding relationships, facilitates feedback and provides exceptional client service.
- Develop and maintain productive and collaborative working relationships with peers and stakeholder.
- Positively influence and participate in change initiatives.
- Continuously develop own expertise in terms of professional, industry and legislation knowledge.
- Contribute to continuous innovation through the development, sharing and implementation of new ideas.
- Take ownership for driving career development.
- Contribute to the financial planning process within area.
- Identify opportunities to enhance cost effectiveness and increase operational efficiency.
- Manage financial and other company resources under your control with due respect.
- Provide input into the risk identification processes and communicate recommendations in the appropriate forum.
