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 appropriate due diligence (such as listening to the policy sales/retention phone conversations).
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.
Make correct decisions regarding acceptance/declining payment of claims based on appropriate documents received and relevant contracts in place.
Correspondence
Keep claimants informed regarding their claim process.
Send appropriate settlement documentation to relevant parties outlining amounts paid and reasons for it.
Contact relevant parties for declined claims and explain reasons thoroughly.
Forward relevant claims correspondence to the reinsurer.
Customer Management
Manage customer requests by carrying out standard activities.
Provide feedback to the complaints department on customer complaints and queries regarding claims decisions.
Comply with current claims policy and procedures, ensuring production targets are met and relevant turnaround times and SLAs are adhered to.
Escalate any red flags/discrepancies to the relevant department as identified.
Administration
Ensure correct banking details are received and captured for accepted claims.
Ensure all appropriate documents are in place relating to a client policy and that appropriate disclosures were made by the life assured.
Update claims statistics correctly and timely, storing all internal and external communication regarding claims in the relevant folder.
Continuous Improvement
Leverage available information to review departmental processes, systems, and protocols for improved efficiencies.
Analyze current performance inhibitors and find solutions for business continuity.
Personal Capability Building
Participate in assessment and development planning activities as well as formal and informal training and coaching.
Maintain an understanding of relevant technology, external regulations, and industry best practices through ongoing education, attending conferences, and reading specialist media.
BEHAVIORAL COMPETENCIES
Decision Quality: Makes good and timely decisions to keep the organization moving forward.
Drives Results: Achieves results consistently, even under tough circumstances.
Customer Focus: Builds strong customer relationships and delivers customer-centric solutions.
Communicates Effectively: Develops and delivers clear communications for different audiences.
Ensures Accountability: Holds self and others accountable to meet commitments.
Being Resilient: Rebounds from setbacks and adversity in difficult situations.
Interpersonal Savvy: Relates openly and comfortably with diverse groups of people.
Manages Complexity: Makes sense of complex information to effectively solve problems.
Plans and Aligns: Plans and prioritizes work to meet commitments aligned with organizational goals.
Manages Conflict: Handles conflict situations effectively and respectfully.
TECHNICAL COMPETENCIES
Data Collection and Analysis: Provides technical guidance to analyze data for claims decision-making.
Medical Knowledge: Applies medical knowledge and provides technical guidance as needed.
Customer Service Delivery: Ensures high customer service standards are met.
Verbal and Written Communication: Uses clear communication skills to express ideas and formulate plans.
Policy and Procedures: Monitors and interprets policies to align with organizational strategies.
Policy and Regulation: Applies knowledge of laws and regulations in the area of expertise.
Numerical Skills: Uses numerical concepts to perform calculations related to claims.
Computer and System Skills: Utilizes standard office equipment and software packages effectively.
Planning and Organizing: Plans and organizes activities to efficiently meet business objectives.
Action Planning: Develops plans based on recommendations and requirements.
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
2 or more years of claims assessing experience in the life insurance industry (Essential)
Experience in a medical environment (Advantageous)
ADDITIONAL INFORMATION
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. 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 verified.
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