Claims Assessor

Introduction Momentum Health Solutions, an entity of Momentum Metropolitan Holdings delivers sustainable, integrated health solutions that meet the needs of clients in the different segments and maximise lifetime client value. We build and maintain a culture of innovation and create value through unique insights of how to achieve specific outcomes by using a defined set of Health capabilities

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Role Purpose 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
• Mathematics and Maths Literacy 60%
• 2 years’ experience in processing claims
• Experience in the assessing of relevant insurance or medical aid claims, paper and/or EDI (desirable)
• Relevant degree or qualification
• 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

Duties & Responsibilities INTERNAL PROCESS

• 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.

CLIENT

• 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.

PEOPLE

• 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.

FINANCE

• 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.

Competencies

• Examining Information
• Interacting with People
• Managing Tasks
• Documenting Facts
• Making Decisions
• Producing Output
• Interpreting Data
• Meeting Timescales