Responsible for quality auditing of processed claims and claim decisions. Responsible for decision making of claims as and when mandated to do so.
Responsibilities
Claim Quality Audit and Decisions
Conduct complex analyses, quality tests and inspections for already processed claims as well as mandated claims.
Insurance Claims Administration
Process assigned straightforward insurance claims, ensuring that each claim is supported by valid documentation and supporting evidence, and meeting defined customer service standards. Authorise claims within delegated authority and refer complex or unresolved issues to senior colleagues.
Data Collection, Analysis & Reporting
Ask questions, collect data from a variety of sources, analyse information and investigate claim.
Make decisions according to established criteria to ensure standardisation across the organisation by accurately administrating claims. Contribute to the preparation of various claims reports for Senior Management.
Work Scheduling and operational compliance
Organise own work schedule in order to get the job done, coordinating with support services and completed work within SLA. Ensure claims are finalised within the set parameters (turnaround time, terms and conditions applied accurately). Remain up to date current and new product knowledge to enable effective decision making.
Administration
Produce, update and provide best practice support to stakeholders on the claims administration process and other departmental systems, in line with claims policy, rules and SLAs.
Document Management
Create, organise and maintain files containing the correspondence relating to policies and matters.
TASKS
Verify prepared insurance claim forms or related documents and review them for completeness.
Provide approval on mandated claims.
Contact involved persons to obtain missing information.
Review insurance policy to determine coverage.
Organise or work with detailed office records, using computers to enter, access, search or retrieve data.
Finalise claims and send to claims handling department.
Skills
Verbal and written Communication
Uses clear and effective verbal and written communications skills independently and provides technical guidance when required on expressing ideas, requesting actions and formulating plans or policies.
Numerical Skills
Uses an understanding of numerical concepts to perform mathematical operations such as report analysis independently and provides technical guidance when required.
Computer Skills
Supports business processes without supervision by understanding and effectively using standard office equipment and standard software packages, while providing technical guidance as needed.
Planning and Organising
Works independently and provides technical guidance when required on planning, organising, prioritising and overseeing activities to efficiently meet business objectives.
Policy and procedures
Works independently and provides technical guidance when required on developing, monitoring, interpreting and understanding policies and procedures, while making sure they match organizational strategies and objectives.
Data Collection and analysis
Works independently and provides technical guidance when required on analyse data and critically evaluate information to ensure accuracy of content and to assist with decision making.
EDUCATION
General Education
- Matric / Grade 12/ SAQA Accredited Equivalent (Essential)
- Regulatory exam 5 (Advantageous)
General Experience
- 1-3 years' claims experience within the Non-Life Financial Services industry (Essential)
SAQA Accredited Equivalent - it is the onus of the applicant to provide TIH andits 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.
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