Claims Assessor/ Approver

An authorised financial service provider, operating within the long-term insurance industry in South Africa, requires the services of a Claims Assessor/Approver.

The primary purpose of this role is to assess, approve, and investigate insurance claims to ensure their validity, compliance with company processes, and adherence to relevant regulations. The claims assessor/approver will be responsible for thoroughly evaluating claims, verifying documentation, and conducting investigations, when necessary, to verify their validity before granting final approval for claims for payout.

Tasks and responsibilities will include but not be limited to:

Key Responsibilities:

(The primary tasks, functions and deliverables of the role\

• Assess claims in compliance with master policy guidelines: Ensure a thorough assessment of claims to approval or repudiation stage in accordance with the established Claims Checklist and adhere to the rules of the master policy governing the specific scheme, policyholder, or claim event.
• Approve claims in compliance with master policy guidelines: Ensure precise adherence to master policy rules governing specific schemes, policyholders, or claim events by the individual responsible for assessing the claim
• Ensure adherence to the SLA and correct allocation of claims : Ensure all claims are assessed and approved within the agreed Service Level Agreements. Under no circumstances are you permitted to approve a claim that you assessed. If you are involved in assessing or processing a claim, you must allocate the claim to another team member for review and approval. This ensures impartiality and adherence to company policy.
• Validate claims and documentation: Assess the validity of claims and associated documentation. Promptly communicate any possible invalid claims.
• Effective communication with clients: Communicate efficiently with clients during the assessment process, requesting additional information within the SLA to facilitate a smooth claims assessment process. Ensure that clients are provided with real-time information on the status of their claims.
• Maintain accurate records of all claims: Execute precise filing for both approved and rejected claims, contributing to streamlined documentation.
• Verify claim payment details for accuracy: Prior to submission to the finance department, meticulously review and ensure the accuracy of all claim payment details.
• Efficiently handle disputes within defined timelines: Resolve disputes promptly, meeting required turnaround times and maintaining positive client relations.
• Address claim-related queries and assist in complaint resolution: Responsively assist with internal and external queries, collecting relevant information to efficiently address complaints and inquiries.
• Support Ombud complaints and investigations: Provide assistance in handling Ombud complaints, showcasing commitment to resolving external grievances.
• Generate and issue proof of payments and official correspondence: Prepare and distribute essential documents, including proof of payments, as well as letters notifying clients of payment or claim rejection.
• Assist clients with claims registers: Support clients by providing necessary information and assistance with claims registers upon request.
• Cultivate a risk-aware culture and report incidents: Actively promote a risk-aware culture, promptly logging any incidents on the risk register to ensure timely resolution.
• Identify and report fraudulent claims: Demonstrate caution in identifying potential fraudulent claims and promptly report findings to the Line Manager.
• Promote a culture of teamwork and meet daily deadlines: Foster a collaborative environment by helping team members to collectively meet daily claims processing deadlines.

Experience & Knowledge required:

• At least 5 years experience in the claims assessing and 3 years experience in claims approval in life, funeral, medical, employee benefits and credit life insurance.
• Policy Administration in the Insurance Industry would be an advantage.
• Client Service experience
• TCF, POPI Act Knowledge
• FAIS Ombud Knowledge

Skills and Abilities:

• Excel, outlook, Microsoft PowerPoint
• Analytical skills - Ability to assess and evaluate complex claim scenarios.
• Attention to Detail
• Excellent communication skills
• Customer Service Orientated
• Good time management skills
• Problem solving skills.
• Conflict resolution skills
• Adaptable
• Ethical, trustworthy with a high level of integrity.

Qualifications:

• Matric certificate / NQF level 4 qualification
• RE5 preferred

Job Type: Permanent

Application Question(s):

• Do you have a RE5 qualification?
• How many years experience do you have in approving funeral insurance ?
• How many years experience do you have in approving credit life insurance
• How many years experience do you have in approving medical insurance
• How many years experience do you have in approving group life insurance

Education:

• High School (matric) (Required)

Experience:

• • Claims Administration within the Insurance Industry: 5 years (Required)

Work Location: In person