Claims Assessor (Zestlife) at Guardrisk

Role Purpose    

• Claims administrative responsibilities in respect of GAP Short Term Insurance Products.
• Ensuring that the principles and outcomes of TCF (Treating Customers Fairly) are practised and achieved in all duties performed and services provided to Zest life customers.

Requirements    

• Matric
• Computer literacy
• FAIS FIT and proper, including RE5
• At least 2 years of experience in short-term or medical health and accident insurance handling.
• At least 2 years of client service experience.
• Good knowledge of the local health industry, including the application of ICD-10 and BHF tariff codes
• Knowledge of the OWLS system is advantageous.

Duties & Responsibilities    

• To adhere to the claims process and guidelines as laid down in terms of TCF, and for HealthMax and ProfmedMedical Aid clients.
• To ensure that you verify and update, if necessary, the client contact and medical aid information on thepolicy record as per the claim documents submitted.
• To validate all claim documents received and to request any outstanding information from the client orbroker as a last resort, as you need to source the documentation yourself on behalf of the client.
• Capture the claim and ensure all documents are linked to the claim record.\
• Capture the claim details as per invoices and medical aid statements once all documents are received.
• Ensure relevant client notes are added to the claim record.
• Ensure only valid claims are paid in accordance with the policy terms and conditions, ensure that the policyoption and commencement date has been considered in determining the validity of the claim.
• Check and ensure policy premiums are up to date and obtain Management’s approval if any premiumoffset is required to be recorded.
• To arrange for closed/rejected claims to be reopened or for additional claims to be lodged based on theinformation at your disposal.
• Ensure the client is kept informed and their claim expectation is adequately addressed and managed bycommunicating or interacting timeously and professionally with our clients telephonically and via e-mail withthe correct template selection and use in your correspondence.
• To identify the fixed discount service providers on a claim and to follow the process and to correctly capturethe discount verified to reduce the claim payment accordingly.
• To assess a minimum of 9 claims per day, with the aim of achieving the target of 11 claims per day.
• To ensure that you attend to, process, and assess your claims within the TAT of 2 days and any outstandinginformation is requested or obtained.
• To maintain and update your claims and tasks in your To Do List on the system for daily managementreporting.
• To note all telephone calls made or received on the claim or policy record.
• To meet the minimum 90% QA standard set for a claims assessor and to strive to achieve 100% accuracy.
• To notify the Manager of any priority claims for escalation or complaints received.
• To be pro-active and to assist the clients with their claims by applying the TCF principles.
• Be creative and use your initiative in resolving outstanding documents so that the claim can be processed.
• Think of working smarter and of ways to improve the process to add value to the clients claim experience.
• You are responsible to ensure that you are competent and fully able to assess any Gap or Dental Gap claimassigned to you.
• You are responsible to ensure that you consistently achieve the daily, weekly, and monthly claims productivityand accuracy targets.
• You are responsible to ensure that you fully understand the GAP product, the claims process, and the systemsso that you can operate efficiently and are competent in your job as a GAP claims assessor.

Competencies    

• Results and solution-driven
• Strong focus on client centricity and service excellence
• Strong problem-solving and decision-making capabilities
• Analytical with attention to detail
• Resilience and ability to work under pressure
• Effective communication skills and professional client management

Deadline:6th April,2026