Intermediate Claims Assessor (Sickness) at PPS

Minimum Requirements    

Education: 

• Medical qualification compulsory (Nursing, Occupational Therapy and Physiotherapy or related).

Experience:

• 4 years’ experience in the insurance industry.
• 3 years’ experience in claims assessment including Income protection, Lump Sum Disability and dread disease.
• Proven work experience as Claims Assessor in customer-facing role.

Knowledge and Skills:

• Must have excellent telephone etiquette.
• Good computer knowledge - MS Outlook, Excel and Word are necessary.
• Good report writing and presentation skills.
• Must have a mature, disciplined and driven personality.
• Ability to work independently as well as being a good team-player with excellent interpersonal skills.
• Attention to detail.
• Deadline/target driven, with ability to work under pressure.
• Logical and analytical.
• Effective time management skills.

Competencies:

• Communication skills (written and verbal).
• Business writing skills.
• Planning and organizing.
• Attention to detail.
• Client centricity.
• Building and maintaining relationships.
• Resilience.

Duties and Responsibilities    

• Process optimization and efficiencies:
• Assessment and management of short-term sickness, critical illness and hospital claims.
• 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 independent specialist.
• Receive Independent Specialist reports and analyze and synopsize the report in context of the claim and PPS Provider Policy.
• Correspondence to clients with respect to claims outcomes and requirements for future claims in order to manage claims.
• Keeping accurate records of all claims assessed in accordance with departmental procedures.
• Deal with first line queries by members and brokers telephonically and via e-mail.
• Deal with Arbitration and Ombudsman cases and collaborate with other stakeholder during the Complaints process.
• Participation in projects to improve departmental service-owning your role in the project and completing tasks as required by providing input.

Risk and Compliance:

• Adhere to internal SLA's to ensure operational efficiency and achievement of agreed customer service standards.
• Proficient in the assessment of claims.
• Must understand claims environment and general claims protocols and processes.
• Ensure adherence to audit requirements.
• Ensure adherence to regulatory and compliance requirements.

People and Culture:

• Checking and Authorization of claims in terms of published delegation of authority.
• Collaboration with relevant stakeholders: Research & Development, Legal, Operational Accounts, Non-disclosure and Internal Control.
• Contribute and assist to review processes and protocols where required to assist in PPS’ delivery of quality claims decisions.
• Forge strong working relationships with stakeholders.

Knowledge Champion:

• Ensure that own knowledge is kept abreast with industry & regulatory information and changes through various internal and external information sources.
• Provide technical information and support.