Claims Manager COID at Rand Mutual - RMA

Purpose of the role:

Reporting to the Claims Operations Manager the incumbent will assist in proactively managing claims at the individual and portfolio level while ensuring high quality and achieving high levels of satisfaction for the members, claimants, dependents, and Service Providers.

The Claims Manager will also assist in ensuring that Class XIII and Class IV Business Claims Teams achieve their operational strategic goals through keeping performance to the highest standards, deliver excellent customer service, while complying with all relevant legislations and all company policies and procedures. The incumbent will also be responsible for leading and supervising the effective and efficient adjudication of COIDA claims.

Qualification and Experience required:

• Minimum of 10 years supervisory experience within the Insurance industry
• FAIS Regulatory Examination (RE1)
• Bachelor’s degree in Administration/Insurance/Health or equivalent OR Medical degree preferably within Occupational Health
• COIDA in Practice or Insurance Qualification an advantage
• Computer literacy: Advanced MS Word, Excel and Outlook
• Good presentation skills and ability to interact with management

Key Areas of Responsibility:

• Manage claims and administration costs.
• Proactively manage individual claims from notification to closure.
• Proactively supervise the proper adjudication of claims.
• Handle complex and fraudulent claims.
• Ensure that all payments are correct and in accordance with company and legislative requirements.
• Feedback claims trends and developments and their potential impact on claims costs.
• Monitor the medical Management of claims aligned to treatment protocols and COIDA limits and work with the Clinical team to generate Authorization of treatment plans and devices.
• Management of Cost associated to the authorization and claims Estimates.
• Ensure that claims are Reviewed and recommendation for TTD Payment, Lump Sum payment or Pension are made.
• Increase first phase Straight Through Processing of claims and ensure that more than 55% of claims are processed through this system.
• Participate, provide input and implement “Treating Customers Fairly” within the Department.
• Identify issues and claims trends in the portfolio, advice Senior Management with recommendation for appropriate and corrective action.
• Handle client’s complaints and appeals.
• Taking ownership of client relationships.
• Build relationships with new and existing clients.
• Continuous improvement of relationship with clients.
• Handling and resolving client inquiries related to service delivery.
• Ensure that customer satisfaction targets are cascaded to all customer facing roles and assessed on a monthly basis.
• Setting staff performance targets and expectations, ensuring that the targets and expectations are achieved through regular monitoring and management.
• Ensuring that Claims staff operate within approved claims authority limits.
• Identify training requirements for staff, through effective staff management and assist them in meeting their training requirements.
• Develop automated performance and individual performance dashboards
• Identify key risks indicators and establish mitigating controls.
• To ensure that expenditure is incurred within the limits of the sanctioned budget.
• To assist in identifying and recruiting new staff members.
• Ensure optimal liaison with stakeholders including but not limited to employers, employees and healthcare providers.
• Management of and participation in Strategic or Operational Projects identified by the Company, within a reasonable time frame and budget.
• Enhance Business processes, workflows and document system enhancements.
• Reviewing trends, variances and making changes to improve performance.
• Ensuring that systems are used effectively to improve accuracy and minimize errors
• Handling complex complaints or difficult customers.
• Able to apply sound financial principles and processes to the business and ensure profitability, compliance and continued growth.
• Use appropriate templates and channels to report progress on a weekly and monthly basis.
• Adhere to deadlines and timeously submit various periodical reports to Claims Management and internal committees
• Ensure accuracy and high quality of reports submitted to Claims Management and internal committees

Knowledge, skills and competency required:

• Knowledge of business policies, processes and procedures, legal compliance and claims environment
• Knowledge of all related applications and processes relevant to the position of Team leader
• Knowledge of Claims processing, approval and payment processes
• Service Orientation/Customer Responsiveness
• Excellence/quality orientation
• Judgement and Decision Making
• Applied Learning
• Planning, Organising and Follow through
• Resilience/Optimism
• Attention to detail
• Presentation skills
• Verbal and written communication
• Interpersonal awareness/empathy
• Customer Focus