Job Description

JOB PURPOSE
Process and pay valid life/disability/dread premium waiver claims by reviewing
claims decisions made by life claims assessors; and manage risk by declining
invalid and fraudulent claims.
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.
Check claims and validate contracts on claims, that are above claims assessor
limits by reviewing claims decisions made by life claims assessors, by applying
specialist medical assessing skills and knowledge and experience.
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.
Audit claim decisions made and processes and procedures followed by life claim
assessors during the assessment process.
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 (Internal and External)
Help manage customers by carrying out activities to complete the customer
request. Provide feedback to the complaints department on customer complaints
and queries regarding outcome of claims decision.
Adhere to SLAs between claims and the complaints department and providing
the complaints department with comprehensive feedback on the background of
the claim and decision made.
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.
Performance Management
Prioritise own workflow and ensure work is completed to the required standards
of productivity, quality and timeliness.
Monitor the performance of the team; allocate work and review completion, take
appropriate corrective action to ensure timeliness and quality. Ensure that
production targets are met, and that relevant turnaround times and SLAs are
adhered to.
Organisational Capability Building
Provide instruction and informal advice to less experienced colleagues within the
team to develop their skills.
BEHAVIORAL COMPETENCIES
Decision Quality
Makes good and timely decisions that keep the organization moving forward. For
example, consistently demonstrates strong judgment; may be sought out by
others for expertise and guidance. Takes smart, independent action in urgent
and non-routine situations, knows when to escalate for others' involvement.
Drives Results
Consistently achieves results, even under tough circumstances. For example,
emphasizes the importance of results; encourages a sense of urgency in others.
challenges poor outcomes or unproductive behaviors. Provides assistance or
encouragement to help others over obstacles.
Customer Focus
Builds strong customer relationships and delivers customer-centric solutions. For
example, keeps in contact with customers to ensure problems are resolved, or to
improve customer service. Studies customer feedback and emerging customer
needs and uses these to determine some creative new ideas.
Communicates Effectively
Develops and delivers multi-mode communications that convey a clear
understanding of the unique needs of different audiences. For example,
disseminates knowledge, insights, and updates in a polished, precise, and
compelling manner. Demonstrates a deep interest in others' comments. Creates
rich documents and reports.
Ensures Accountability
Holds self and others accountable to meet commitments. For example, tracks
performance and strives to remain effective, learning from both successes and
failures. Readily takes on challenges or difficult tasks and has reputation for
delivering on commitments.
Being Resilient
Rebounds from setbacks and adversity when facing difficult situations. For
example, has excellent composure and professionalism, even in very difficult situations, acts as a steadying force or role model for others. Skilfully
overcomes obstacles, learns from failures, and uses these lessons to improve
subsequent efforts.
Interpersonal Savvy
Relates openly and comfortably with diverse groups of people. For example,
recognizes even subtle social cues and nimbly responds to others' needs and
preferences. Helps to defuse difficult interpersonal situations by showing high
levels of tact, sensitivity, and consideration. Builds rapport with ease.
Plans and Aligns
Plans and prioritizes work to meet commitments aligned with organizational
goals. For example, strengthens alignment and coordination between own work
and others', providing well-sequenced activities and exact time frames. Foresees
and resolves many potential bottlenecks and delays.
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.
Manages Conflict
Handles conflict situations effectively, with a minimum of noise. For example,
takes a positive approach to conflicts; helps dispel tension; seeks guidance and
feedback on managing conflict; delivers controversial viewpoints candidly and
sensitively, does not take arguments personally.
SKILLS Medical knowledge
Apply comprehensive knowledge / skill, acts with independence and provides
guidance and training to others.
Medical Industry knowledge., Knowledge of Human Anatomy.
Data Collection and analysis
Provide guidance when required to analyse data to help guide decision making
on the claims.
Customer Service Delivery
Provide guidance as needed on meeting high customer service standards.
Verbal and Written Communication
Use clear and effective verbal and written communication skills and provides
guidance when required to express ideas, request actions and formulate plans or
policies.
Policy and procedures
Provide guidance when required to develop, monitor, interpret and understand
policies and procedures, while making sure they match organisational strategies
and objectives.
Knowledge of Life Insurance Principles.
Policy and Regulation
Provide guidance when required to interpret and apply knowledge of laws,
regulations and policies in area of expertise.
Knowledge of 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 Organising
Plan, organise, prioritise 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
4 or more years claims assessing experience in the life insurance industry (Essential)
Experience in a medical environment (Advantageous)
Managerial Experience
Experience of general supervision of more junior colleagues (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.