Job Description

JOB PURPOSEProcess and pay valid life/disability/dread premium waiver claims by reviewingclaims decisions made by life claims assessors; and manage risk by declininginvalid and fraudulent claims.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.Check claims and validate contracts on claims, that are above claims assessorlimits by reviewing claims decisions made by life claims assessors, by applyingspecialist medical assessing skills and knowledge and experience.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.Audit claim decisions made and processes and procedures followed by life claimassessors during the assessment process.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 informed at all times 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 Management (Internal and External)Help manage customers by carrying out activities to complete the customerrequest. Provide feedback to the complaints department on customer complaintsand queries regarding outcome of claims decision.Adhere to SLAs between claims and the complaints department and providingthe complaints department with comprehensive feedback on the background ofthe claim and decision made.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 that thecorrect 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 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.Performance ManagementPrioritise own workflow and ensure work is completed to the required standardsof productivity, quality and timeliness.Monitor the performance of the team; allocate work and review completion, takeappropriate corrective action to ensure timeliness and quality. Ensure thatproduction targets are met, and that relevant turnaround times and SLAs areadhered to.Organisational Capability BuildingProvide instruction and informal advice to less experienced colleagues within theteam to develop their skills.BEHAVIORAL COMPETENCIESDecision QualityMakes good and timely decisions that keep the organization moving forward. Forexample, consistently demonstrates strong judgment; may be sought out byothers for expertise and guidance. Takes smart, independent action in urgentand non-routine situations, knows when to escalate for others' involvement.Drives ResultsConsistently 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 orencouragement to help others over obstacles.Customer FocusBuilds strong customer relationships and delivers customer-centric solutions. Forexample, keeps in contact with customers to ensure problems are resolved, or toimprove customer service. Studies customer feedback and emerging customerneeds and uses these to determine some creative new ideas.Communicates EffectivelyDevelops and delivers multi-mode communications that convey a clearunderstanding of the unique needs of different audiences. For example,disseminates knowledge, insights, and updates in a polished, precise, andcompelling manner. Demonstrates a deep interest in others' comments. Createsrich documents and reports.Ensures AccountabilityHolds self and others accountable to meet commitments. For example, tracksperformance and strives to remain effective, learning from both successes andfailures. Readily takes on challenges or difficult tasks and has reputation fordelivering on commitments.Being ResilientRebounds from setbacks and adversity when facing difficult situations. Forexample, has excellent composure and professionalism, even in very difficult situations, acts as a steadying force or role model for others. Skilfullyovercomes obstacles, learns from failures, and uses these lessons to improvesubsequent efforts.Interpersonal SavvyRelates openly and comfortably with diverse groups of people. For example,recognizes even subtle social cues and nimbly responds to others' needs andpreferences. Helps to defuse difficult interpersonal situations by showing highlevels of tact, sensitivity, and consideration. Builds rapport with ease.Plans and AlignsPlans and prioritizes work to meet commitments aligned with organizationalgoals. For example, strengthens alignment and coordination between own workand others', providing well-sequenced activities and exact time frames. Foreseesand resolves many potential bottlenecks and delays.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.Manages ConflictHandles conflict situations effectively, with a minimum of noise. For example,takes a positive approach to conflicts; helps dispel tension; seeks guidance andfeedback on managing conflict; delivers controversial viewpoints candidly andsensitively, does not take arguments personally.SKILLS Medical knowledgeApply comprehensive knowledge / skill, acts with independence and providesguidance and training to others.Medical Industry knowledge., Knowledge of Human Anatomy.Data Collection and analysisProvide guidance when required to analyse data to help guide decision makingon the claims.Customer Service DeliveryProvide guidance as needed on meeting high customer service standards.Verbal and Written CommunicationUse clear and effective verbal and written communication skills and providesguidance when required to express ideas, request actions and formulate plans orpolicies.Policy and proceduresProvide guidance when required to develop, monitor, interpret and understandpolicies and procedures, while making sure they match organisational strategiesand objectives.Knowledge of Life Insurance Principles.Policy and RegulationProvide guidance when required to interpret and apply knowledge of laws,regulations and policies in area of expertise.Knowledge of legal contract principles.Numerical SkillsUse an understanding of numerical concepts to perform mathematical operationsto 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 OrganisingPlan, organise, prioritise 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 (Advantageous)Class of Business Certification (Advantageous)EXPERIENCEGeneral Experience4 or more years claims assessing experience in the life insurance industry (Essential)Experience in a medical environment (Advantageous)Managerial ExperienceExperience 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.

1Life Insurance