RESPONSIBILITIES
Claims Data Collection & Analysis
Ask questions, collect data from a variety of sources, analyze information and investigate claims. Ensure that the client policy is valid through the appropriate due diligence (such as listening to the policy sales/retention phone conversation).
Medically assess the validity of the claim by applying specialist medical assessing skills and knowledge.
Ensure that relevant waiting periods have expired and that all premiums have been received on the policy.
Ensure that the correct decision is made regarding acceptance/declining payment of claim based on appropriate documents received and relevant contract in place.
Correspondence
Ensure that a claimant is kept informed at all times regarding their claim process. Ensure that the appropriate settlement documentation is sent to the relevant parties outlining the amounts paid and the reasons for it; and ensure that the relevant parties for a declined claim are contacted and the reasons for the claim being declined are explained thoroughly.
Ensure that relevant claims correspondence is forwarded to the reinsurer.
Customer Management
Help manage customer requests by carrying out standard activities. Provide feedback to the complaints department on customer complaints and queries regarding the outcome of claims decisions.
Comply with current claims policy and procedures, ensure that production targets are met, and that relevant turnaround times and SLAs are adhered to.
Appropriately escalate any red flags/discrepancies to the relevant department (for example, forensics) as and when identified.
Administration
Ensure that the correct banking details are received and captured, and that the correct amount in terms of an accepted claim is paid to the appropriate parties.
Ensure that all appropriate documents are in place relating to a client policy and ensure that the appropriate disclosures were made by the life assured.
Ensure claims statistics are updated correctly and timely, and that all internal and external communication regarding the claim is stored in the relevant folder.
Continuous Improvement
Leverage all available information from our partners, the industry, and internally to ensure we are constantly reviewing our departmental processes, systems, and protocols with a view to improve efficiencies. Analyze current performance inhibitors and find solutions to ensure business continuity.
Personal Capability Building
Develop own capabilities by participating in assessment and development planning activities, as well as formal and informal training and coaching. Maintain an understanding of relevant technology, external regulation, and industry best practices through ongoing education, attending conferences, and reading specialist media.
TECHNICAL
Data Collection and Analysis
Provide technical guidance when required to analyze data to help guide decision making on the claims.
Medical Knowledge
Apply concepts of knowledge/skill and provide technical guidance when required.
Basic Medical Industry knowledge; Knowledge of Human Anatomy.
Customer Service Delivery
Provide technical guidance as needed on meeting high customer service standards.
Verbal and Written Communication
Use clear and effective verbal and written communication skills and provide technical guidance when required to express ideas, request actions, and formulate plans or policies.
Policy and Procedures
Monitor, interpret, and understand policies and procedures, ensuring they match organizational strategies and objectives.
Knowledge of Life Insurance Principles.
Policy and Regulation
Interpret and apply knowledge of laws, regulations, and policies in the area of expertise.
Basic legal contract principles.
Numerical Skills
Use an understanding of numerical concepts to perform mathematical operations to calculate claims.
Calculation of claims.
Computer and System Skills
Support business processes by understanding and effectively using standard office equipment and in-house and standard software packages.
Basic computer skills; Proficient in MS Office.
Planning and Organizing
Plan, organize, prioritize, and oversee activities to efficiently meet business objectives.
Action Planning
Develop appropriate plans or perform necessary actions based on recommendations and requirements.
EDUCATION
General Education
Grade 12/SAQA Accredited Equivalent (Essential); Recognized FSCA qualification (Essential); Regulatory exam 5 (Essential); Nursing/relevant medical qualification (Advantageous); Class of Business Certification (Advantageous).
EXPERIENCE
General Experience
2 or more years claims assessing experience in the life insurance industry (Essential); Experience in a medical environment (Advantageous).
ADDITIONAL INFORMATION
*SAQA Accredited Equivalent - it is the onus of the applicant to provide 1Life and its subsidiaries with certified evidence that their qualification(s) meet the equivalent NQF level required for this role at the time of application. *Financial Sector Conduct Authority (FSCA) competency requirements: FAIS recognized 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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