Intermediate Claims Assessor (Sickness)

Job Advert Summary

Overall Job Purpose

This role reports to the Team Manager Claims. Responsible for assessment and processing of short-term Sickness, Critical Illness and Hospital claims. The incumbent will deal with technical and complex claims queries and/or complaints providing an excellent service offering.

An insurance assessor, also known as a claims assessor, is a professional who evaluates insurance claims to ensure the individual claiming receives justifiable compensation. They review all aspects of the claim, financials and medical reports.

Minimum Requirements

Education

• Compulsory medical qualifications (i.e. Nursing, Occupational Therapy and Physiotherapy or related).

Experience

• 4 years’ experience in the insurance industry
• 3 years’ experience in claims assessment including Income protection, Lump Sum Disability and dread disease
• Proven work experience as Claims Assessor in customer-facing role.

Duties and Responsibilities

Key Responsibilities

Process optimization and efficiencies

• Assessment and management of short-term sickness, critical illness and hospital claims
• Check the technical aspects of the claim – Inclusive of potential non-disclosure, and exclusions.
• Review all medical information on file, analyze and synopsize information at hand.
• Determine and record additional required information
• Decide on referral to an independent specialist
• Receive Independent Specialist reports and analyze and synopsize the report in context of the claim and PPS Provider Policy.
• Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
• Keeping accurate records of all claims assessed in accordance with departmental procedures.
• Deal with first line queries by members and brokers telephonically and via e-mail

Risk and Compliance

• Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards
• Proficient in the assessment of claims
• Must understand claims environment and general claims protocols and processes
• Ensure adherence to audit requirements
• Ensure adherence to regulatory and compliance requirements

People and Culture

• Checking and Authorization of claims in terms of published delegation of authority.
• Collaboration with relevant stakeholders: Research & Development, Legal, Operational Accounts, Non-disclosure and Internal Control
• Contribute and assist to review processes and protocols where required to assist in PPS’ delivery of quality claims decisions
• Forge strong working relationships with stakeholders

Knowledge Champion

• Ensure that own knowledge is kept abreast with industry & regulatory information and changes through various internal and external information sources
• Provide technical information and support

Knowledge and Skills

• Must have excellent telephone etiquette
• Good computer knowledge - MS Outlook, Excel and Word are necessary
• Good report writing and presentation skills
• Must have a mature, disciplined and driven personality
• Ability to work independently as well as being a good team-player with excellent interpersonal skills
• Attention to detail
• Deadline/target driven, with ability to work under pressure
• Logical and analytical
• Effective time management skills

Competencies

• Communication skills (written and verbal)
• Business writing skills
• Planning and organizing
• Attention to detail
• Client centricity
• Building and maintaining relationships
• Resilience