Job Description

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.
BEHAVIORAL COMPETENCIES
Decision quality
Makes good and timely decisions that keep the organization moving forward. For
example, knows when to act independently and when to escalate issues.
Integrates various inputs, decision criteria, and trade-offs to make effective
decisions. Typically makes good independent decisions.
Drives results
Consistently achieves results, even under tough circumstances. For example,
regularly pushes self to achieve outstanding outcomes; consistently establishes
bold goals for own performance; is passionate about excellent results and
significant contributions. Shows great tenacity to complete goals/initiatives in a
timely way.
Customer focus
Builds strong customer relationships and delivers customer-centric solutions.
For example, probes deeply into customer needs to identify less obvious
interests or expectations. Consistently goes above and beyond to understand
customer requirements and surpass their expectations.
Communicates effectively
Develops and delivers multi-mode communications that convey a clear
understanding of the unique needs of different audiences. For example, listens
attentively and takes an interest. Keeps others well informed; conveys
information clearly, concisely, and professionally when speaking or writing.
Ensures accountability
Holds self and others accountable to meet commitments. For example, accepts
responsibility for own work, both successes and failures. Handles fair share and
does not make excuses for problems. Usually meets commitments to others.
Being resilient
Rebounds from setbacks and adversity when facing difficult situations. For
example, is calm and professional in difficult situations; continues to work
toward objectives. Overcomes obstacles without becoming discouraged; draws
lessons from failures. Recovers from setbacks and adversity.
Interpersonal savvy
Relates openly and comfortably with diverse groups of people. For example,
takes time to build rapport in meetings; speaks about common interests and
priorities; shows tact and sensitivity in difficult interpersonal situations. Maintains
productive relationships with a wide variety of people and from a range of
backgrounds.
Manages complexity
Makes sense of complex, high quantity, and sometimes contradictory information
to effectively solve problems. For example, looks at complex issues from
multiple angles; explores issues to uncover underlying issues and root causes.
sees the main consequences and implications of different options.
Plans and aligns
Plans and prioritizes work to meet commitments aligned with organizational
goals. For example, outlines clear plans that put actions in a logical sequence.
conveys some time frames. Aligns own work with relevant workgroups. Takes
some steps to reduce bottlenecks and speed up the work.
Manages conflict
Handles conflict situations effectively, with a minimum of noise. For example,
disagrees with others in a respectful and tactful manner; handles conflicts and
differences of opinion in a calm, composed manner, rebounds from conflicts
without animosity.
TECHNICAL COMPETENCIES
Data Collection and analysis
Provide technical guidance when required to analyse data to help guide decision
making on the claims.
Medical knowledge
Apply concepts of knowledge / skill and able to provide technical guidance when
required.
Basic Medical Industry knowledge.; Knowledge of Human Anatomy..
Customer Service Delivery
Provide technical guidance as needed on meeting high customer service
standards.
Verbal and Written Communication
Use clear and effective verbal and written communication skills and provides
technical guidance when required to express ideas, request actions and
formulate plans or policies.
Policy and procedures
Monitor, interpret and understand policies and procedures, while making sure
they match organizational strategies and objectives.
Knowledge of Life Insurance Principles.
Policy and Regulation
Interpret and apply knowledge of laws, regulations and policies in area of
expertise.
Basic legal contract principles.
Numerical Skills
Use an understanding of numerical concepts to perform mathematical
operations to calculate claims.
Calculation of claims.
Computer and system skills
Support business processes by understanding and effectively using standard
office equipment and in house and standard software packages.
Basic computer skills.; Proficient in MS Office..
Planning and Organizing
Plan, organize, prioritize and oversee activities to efficiently meet business
objectives.
Action Planning
Develop appropriate plans or perform necessary actions based on
recommendations and requirements.
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)
ADDITIONAL INFORMATION
*SAQA Accredited Equivalent - It is the onus of the applicant to provide 1Life and
its subsidiaries with certified evidence that their qualification(s) meet the
equivalent NQF level required for this role at time of application. As a registered
Financial Service Provider, we are mandated to ensure that all our
representatives are and remain fit and proper at all times. By applying for this
role, you consent to having your relevant qualification and or accreditation or
confirm that you are working towards meeting the competency requirements.
You further consent to the relevant information being verified.