Group Schemes Claims Assessor at Absa South Africa

Job Summary

• To provide and maintain a consulting service to employers, retirement funds and other stakeholders with regard to employee benefit risk management and incapacity management in the workplace. This includes advice on benefit structures and management of ill or disabled employees in the workplace

Job Description

Assessment of disability claims

• Analyse the claimant’s medical condition, vocational requirements as well as fund/insurer rules and policies to determine the eligibility for benefits.
• Consider the relevant Fund/Insurer rules and policies to determine a member’s eligibility for benefits e.g., determine if the members medical condition was pre-existing
• Evaluate the extent of a member’s disability against his/ her occupational duties
• Assess and Compile a recommendation on the validity of the claim to be submitted to the client in a written report
• Manage appeals arising by reviewing claim documentation against issues that are either medical and/or legal in nature. This includes determining and sourcing of new medical evidence and/or technical information and re-evaluation in terms of the rules of the Fund
• Provide medical and technical recommendation to the relevant Fund trustees

Consulting to clients on claims

• Respond to product queries from members and clients on claims and the related decisions and outcomes of these
• Respond to queries from members and clients on individuals claims applications telephonically and email
• Provide suggestions and advise to clients on the management of individual claims
• Provide suggestions and advice to clients on the management of the claims
• Discuss the disability reports with clients in order to identify trends and issues of concerns – and provide recommendations on interventions

Authorisation of member risk benefits

• Compilation of claim decision letter in terms of the medical, legal and financial outcome of the claim.
• Authorise payment of claims and medical accounts received from medical and paramedical practitioner

Reporting on claims

• Provide management information to clients on trends and statistics related to claims
• Ensure that the reports are sent to the clients according to the SLA’s in place

Disability Management

• Determine cases that require disability management based on medical diagnosis and prognosis
• Implement and monitor disability management programmes for all designated cases by obtaining feedback from relevant rehabilitation practitioners
• Assess viability, costs, duration and outcome of disability case management
• Recommend claimant return to work in their own role; a modified or completed alternative role; or submit for long term disability. Consult with line management to assist in finding a suitable alternative role for the claimant

Education

• Higher Diplomas: Business, Commerce and Management Studies (Required)