Claims Investigator Personal Lines at Momentum Metropolitan Holdings Limited

Role Purpose    

• A claims investigator identifies and prevents fraudulent claims and manages the expenditure on settled claims.

Requirements    

• Matric
• Minimum experience of 3 years investigative experience in a short-term personal claims environmen
• Completion of an investigations programme would be beneficial
• FAIS accreditation or a FAIS recognised qualification will be highly beneficial 

Duties & Responsibilities    

• Receive personal line claims identified by the fraud prediction model for validation
• Confirm merits of each claim through comprehensive assessment of the item and incident
• Apply the policy to ensure the loss is covered in terms of the contract
• Compile a comprehensive report on all findings and make a recommendation on a claim based on merits/evidence found during the validation process
• Refer all recommendations not within your mandate to the line manager for approval Irrespective of the outcome of the claim the broker, client and claims advisor to be notified (rejected claims to be communicated verbally and in writing)
• The key focus of a claims investigator is to limit financial losses due to a policy/claim fraud and to finalise and adjust claims accurately
• Obtain all evidence in a proper manner to ensure that it is admissible as evidence in a court of law Act as complainant where fraud is found and render all assistance and evidence to ensure the prosecution of the person who committed/attempted to commit fraud Assist/influence other areas of the business once an investigation is concluded, i.e. report on the quality of the sale/policy wording and application or adjustment of underwriting criteria
• Report on any risks identified and suggested controls and report any other failures which influences the merits of an investigation

Internal Process: 

• Enhance service delivery in the claims departments Contribute to optimising work practices and procedures via suggestions
• Up skill/influence claims advisors by sharing knowledge
• Effectively build, maintain and manage relationships with clients, brokers, service providers and business partners
• Ensure investigations are done in a professional manner and all parties are updated regularly on the progress
• Achieve minimum standards with regards to saving ratios, turnaround time,
• Customer Satisfaction scores, Ombudsman overturned ratios and expense ratios

People: 

• Live the Momentum values Interact with colleagues and supply manager investigation results Interact with other business units i.e. claims, client services, brokers, compliance, legal etc
• Build relation/interact with support services to ensure efficiency Interact with clients, brokers and service providers

Competencies    

• Attention to detail
• Team player
• Analytical thinking
• Work independetly
• Communicate with impact