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.

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.