Claims Assessor at The Unlimited

Purpose of the Role:

An exciting opportunity for you to use your specialist technical medical knowledge to Assess Claims. The successful candidate will be responsible for assessing all Death, Illness and Hospital Claims. Ideally, we’re looking for a Claims Assessor with +5 years’ experience and this role is ideally suited to an individual with a medical background such as nursing or paramedics.

Key Responsibilities:

•  Assessment and management of Death Claims Comprises of (Natural and Accidental Death claims), All Accidental claims (Motor Vehicle Accidents, Burns, Murder etc.) and Illness claims. 
• Full and accurate assessment of all claims documents, specifically that all the requirements have been received and that all fraud checks were done
• Confirming the validity of the policy and the quantum of cover.
• Ensuring appropriate telephonic confirmations with external parties (undertaker, police, government mortuary, hospital etc) are done timeously.
• Ensuring all claim notes and information relevant to a specific claim are updated correctly on the system.
• Liaise with the claims team, legal department, risk assessment unit, medical team and management for the claim’s assessment process. 
• Assist with claims audits and provide reports to clients.
• Maintaining professional telephonic and written communication with customers, both external and internal.
• Maintain confidentiality – client and Company
• Assisting with special projects when asked to.
• 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 Investigation Officer.
• Prepare detailed summary for the investigating officer to proceed.
• Receive Investigation reports analyze and synopsize the report in context of the claim and PPS Provider Policy.
• Keeping accurate records of all claims assessed in accordance with departmental procedures.
• Deal with ombudsman cases and collaborate with other stakeholder during the Complaints process
• Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
• Deal with first line queries by claims team leaders and via e-mail
• Ability to collaborate with other stakeholders within the claims management chain
• Participation in projects to improve departmental service-owning your role in the project and completing tasks as required by providing input.
• Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards
• Must be able to apply clinical knowledge and skills to manage claims

Knowledge and Experience:

• Matric (Grade 12)
• A Diploma in Nursing would be advantageous.
• Degree in Occupational Therapy, Physiotherapy, or Psychology (advantageous) 
• Experience in the insurance industry and +5 years’ experience in claims assessments
• Proficient in the assessment and management of claims
• Must understand claims environment and general claims protocols and processes

Skill Competencies:

• Attention to detail
• Deadline/target driven, with ability to work under pressure
• Logical and analytical
• Effective time management skills
• Ensure adherence to audit requirements
• Ensure adherence to regulatory and compliance requirements

Personal Characteristics:

• Good judgement & decisiveness
• Good problem solving and investigating skills
• The candidate must be reliable, and results orientated.
• Ability to work independently as well as being a good team-player with excellent interpersonal skills