Job Description

RESPONSIBILITIESClaims Data Collection & AnalysisAsk questions, collect data from a variety of sources, analyse information andinvestigate claim. Ensure that the client policy is valid through the appropriatedue diligence (such as listening to the policy sales/retention etc. phoneconversation.Medically assess the validity of the claim by applying specialist medicalassessing skills and knowledge.Ensure that relevant waiting periods have expired and that all premiums havebeen received on the policy.Ensure that the correct decision is made with regards to acceptance/decliningpayment of claim based on appropriate documents received and relevantcontract in place.CorrespondenceEnsure that a claimant is kept always informed with regards to their claimprocess. To ensure that the appropriate settlement documentation is sent to theappropriate parties outlining the amounts paid and the reasons for it; and ensurethat the relevant parties for a declined claim are contacted and the reasons forthe claim being declined is explained thoroughly.Ensure that relevant claims correspondence is forwarded to the reinsurer.Customer ManagementHelp manage customer by carrying out standard activities to complete thecustomer request. Provide feedback to the complaints department on customercomplaints and queries regarding outcome of claims decision.Comply with current claims policy and procedures and ensure that productiontargets are met and that relevant turnaround times and SLA's are adhered to.To appropriately escalate any red flags / discrepancies to the relevantdepartment (for example forensics) as and when identified.AdministrationTo ensure that the correct banking details are received and captured and thatthe correct amount in terms of an accepted claim is paid to the appropriateparties.Ensure that all appropriate documents are in place relating to a client policy andensure that the appropriate disclosures were made by the life assured.Ensure claims statistics are updated correctly and timeously and that all internaland external communication regarding the claim is stored on the relevant folder.Continuous ImprovementLeverage all available information from our partners, the industry, and internallyto ensure we are constantly reviewing our departmental processes, systems andprotocols with a view to improve efficiencies. Analyse current performanceinhibitors and finding solutions to ensure business continuity.Personal Capability BuildingDevelop own capabilities by participating in assessment and developmentplanning activities as well as formal and informal training and coaching. Developand maintain an understanding of relevant technology, external regulation, andindustry best practices through ongoing education, attending conferences, andreading specialist media.BEHAVIORAL COMPETENCIESDecision qualityMakes good and timely decisions that keep the organization moving forward. Forexample, knows when to act independently and when to escalate issues.Integrates various inputs, decision criteria, and trade-offs to make effectivedecisions. Typically makes good independent decisions.Drives resultsConsistently achieves results, even under tough circumstances. For example,regularly pushes self to achieve outstanding outcomes; consistently establishesbold goals for own performance; is passionate about excellent results andsignificant contributions. Shows great tenacity to complete goals/initiatives in atimely way.Customer focusBuilds strong customer relationships and delivers customer-centric solutions.For example, probes deeply into customer needs to identify less obviousinterests or expectations. Consistently goes above and beyond to understandcustomer requirements and surpass their expectations.Communicates effectivelyDevelops and delivers multi-mode communications that convey a clearunderstanding of the unique needs of different audiences. For example, listensattentively and takes an interest. Keeps others well informed; conveysinformation clearly, concisely, and professionally when speaking or writing.Ensures accountabilityHolds self and others accountable to meet commitments. For example, acceptsresponsibility for own work, both successes and failures. Handles fair share anddoes not make excuses for problems. Usually meets commitments to others.Being resilientRebounds from setbacks and adversity when facing difficult situations. Forexample, is calm and professional in difficult situations; continues to worktoward objectives. Overcomes obstacles without becoming discouraged; drawslessons from failures. Recovers from setbacks and adversity.Interpersonal savvyRelates openly and comfortably with diverse groups of people. For example,takes time to build rapport in meetings; speaks about common interests andpriorities; shows tact and sensitivity in difficult interpersonal situations. Maintainsproductive relationships with a wide variety of people and from a range ofbackgrounds.Manages complexityMakes sense of complex, high quantity, and sometimes contradictory informationto effectively solve problems. For example, looks at complex issues frommultiple angles; explores issues to uncover underlying issues and root causes.sees the main consequences and implications of different options.Plans and alignsPlans and prioritizes work to meet commitments aligned with organizationalgoals. For example, outlines clear plans that put actions in a logical sequence.conveys some time frames. Aligns own work with relevant workgroups. Takessome steps to reduce bottlenecks and speed up the work.Manages conflictHandles conflict situations effectively, with a minimum of noise. For example,disagrees with others in a respectful and tactful manner; handles conflicts anddifferences of opinion in a calm, composed manner, rebounds from conflictswithout animosity.TECHNICAL COMPETENCIESData Collection and analysisProvide technical guidance when required to analyse data to help guide decisionmaking on the claims.Medical knowledgeApply concepts of knowledge / skill and able to provide technical guidance whenrequired.Basic Medical Industry knowledge.; Knowledge of Human Anatomy..Customer Service DeliveryProvide technical guidance as needed on meeting high customer servicestandards.Verbal and Written CommunicationUse clear and effective verbal and written communication skills and providestechnical guidance when required to express ideas, request actions andformulate plans or policies.Policy and proceduresMonitor, interpret and understand policies and procedures, while making surethey match organizational strategies and objectives.Knowledge of Life Insurance Principles.Policy and RegulationInterpret and apply knowledge of laws, regulations and policies in area ofexpertise.Basic legal contract principles.Numerical SkillsUse an understanding of numerical concepts to perform mathematicaloperations to calculate claims.Calculation of claims.Computer and system skillsSupport business processes by understanding and effectively using standardoffice equipment and in house and standard software packages.Basic computer skills.; Proficient in MS Office..Planning and OrganizingPlan, organize, prioritize and oversee activities to efficiently meet businessobjectives.Action PlanningDevelop appropriate plans or perform necessary actions based onrecommendations and requirements.EDUCATIONGeneral EducationGrade 12/ SAQA Accredited Equivalent (Essential)Recognized FSCA qualification (Essential)Regulatory exam 5 (Essential)Nursing/relevant medical qualification (AdvantageousClass of Business Certification (Advantageous)EXPERIENCEGeneral Experience2 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 andits subsidiaries with certified evidence that their qualification(s) meet theequivalent NQF level required for this role at time of application. As a registeredFinancial Service Provider, we are mandated to ensure that all ourrepresentatives are and remain fit and proper at all times. By applying for thisrole, you consent to having your relevant qualification and or accreditation orconfirm that you are working towards meeting the competency requirements.You further consent to the relevant information being verified.

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