Junior Quality Decision Making Consultant at Telesure Investment Holdings (TIH)

Job Purpose

• Reviewing, vetting and endorsing decisions on all claim types handled in the claims operational area to control associated claims cost, efficiency and risk controls associated with claims decision making.

Responsibilities

Operational Compliance

• Develop knowledge and understanding of the organization's policies and procedures and of relevant regulatory codes and codes of conduct to ensure own work adheres to those standards. Obtain authorization from a supervisor or manager for any exceptions from mandatory procedure.
• Check claims put forward for decision or amendments to original decision as well as all other supporting decisions taken throughout the claims process by adherence against the required standard.
• Identify trends of non-adherence to specific rules and guidelines.
• Escalate disputed recommendations to the Quality of Decision Making Specialist for dispute resolution purposes.
• Uphold agreed service level agreements (set turnaround times) to ensure customer satisfaction and retention.

Data Collection, Analysis, Insights and Reporting

• Collate and analyze data using pre-set tools, methods and formats. Involves working independently.
• Extract and combine data to generate standard reports.
• Report trend findings to Manager Risk and Decision Making. 
• Evaluate the effectiveness of rules, guidelines and processes application. 
• Keep record, measure and track performance agreed standards to inform decision making in the relevant area of responsibility. 
• Request additional validation on claims to enable the approval or denying of claims.

Improvement / Innovation

• Identify shortcomings in existing processes, systems and procedures, and use established change management programs to address them.
• Make recommendations for implementation on continuous improvement opportunities pertaining to rules, guidelines and processes.

Recommendations

• Provide information and clarification on existing procedures, processes and precedents.
• Provide final sign off and endorsement of decisions put forward. 
• Provide detailed input to line managers to enable coaching initiatives.

Stakeholder Engagement

• Assist with stakeholder engagement by arranging actions, meetings, events, and supporting materials to promote stakeholder understanding and commitment.
• Provide support and assistance to claims processors on complicated or unusual claims.
• Effectively build, maintain and manage relationships with internal colleagues.

Education

• Grade 12/ SAQA Accredited Equivalent (Essential); FAIS recognised qualification (Essential)

Experience

• 2 or more years claims administration and validation experience in a claims department within the short-term insurance industry (Essential); 1 or more years experience in a claims decision making role within a claims department within the short-term insurance industry (Advantageous);    1 or more years experience working with internal claims operating systems (Advantageous).