Life Claims Assessor at 1 Life Insurance

RESPONSIBILITIES

Claims Data Collection & Analysis

• Ask questions, collect data from a variety of sources, analyse information and investigate claim. Ensure that the client policy is valid through the appropriate due diligence (such as listening to the policy sales/retention etc. phone conversation.
• Medically assess the validity of the claim by applying specialist medical assessing skills and knowledge.
• Ensure that relevant waiting periods have expired and that all premiums have been received on the policy.
• Ensure that the correct decision is made with regards to acceptance/declining payment of claim based on appropriate documents received and relevant contract in place.

Correspondence

• Ensure that a claimant is kept always informed with regards to their claim process.
• To ensure that the appropriate settlement documentation is sent to the appropriate parties outlining the amounts paid and the reasons for it; and ensure that the relevant parties for a declined claim are contacted and the reasons for the claim being declined is explained thoroughly.
• Ensure that relevant claims correspondence is forwarded to the reinsurer.

Customer Management

• Help manage customer by carrying out standard activities to complete the customer request.
• Provide feedback to the complaints department on customer complaints and queries regarding outcome of claims decision.
• Comply with current claims policy and procedures and ensure that production targets are met and that relevant turnaround times and SLA's are adhered to.
• To appropriately escalate any red flags / discrepancies to the relevant department (for example forensics) as and when identified.

Administration

• To ensure that the correct banking details are received and captured and that the correct amount in terms of an accepted claim is paid to the appropriate parties.
• Ensure that all appropriate documents are in place relating to a client policy and ensure that the appropriate disclosures were made by the life assured.
• Ensure claims statistics are updated correctly and timeously and that all internal and external communication regarding the claim is stored on the relevant folder.

Continuous Improvement

• Leverage all available information from our partners, the industry, and internally to ensure we are constantly reviewing our departmental processes, systems and protocols with a view to improve efficiencies.
• Analyse current performance inhibitors and finding solutions to ensure business continuity.

Personal Capability Building

• Develop own capabilities by participating in assessment and development planning activities as well as formal and informal training and coaching.
• Develop and maintain an understanding of relevant technology, external regulation, and industry best practices through ongoing education, attending conferences, and reading specialist media.

EDUCATION

General Education

• Grade 12/ SAQA Accredited Equivalent (Essential)
• Recognized FSCA qualification (Essential)
• Regulatory exam 5 (Essential)
•  Nursing/relevant medical qualification (Advantageous
•  Class of Business Certification (Advantageous)

EXPERIENCE

General Experience

• 2 or more years claims assessing experience in the life insurance industry (Essential)
• Experience in a medical environment (Advantageous)