Talent Pool: Claims Assessor MMH261030-4

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 - essential
• Relevant degree or qualification - desirable
• 1-2 years experience in processing claims - essential
• Experience in assessing of relevant medical aid claims, paper and/or EDI - (desirable)
• 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 and 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 client's 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.

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