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 informed at all times 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. Analyze 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.

TECHNICAL

Data Collection and analysis

Provide technical guidance when required to analyze 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. Financial Sector Conduct Authority (FSCA) competency requirements: FAIS recognised qualifications / Regulatory Examinations / Class of Business Certification and / or CPD according to your DOFA (where applicable). 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