Life Claims Assessor

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 always informed 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. 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.

BEHAVIORAL COMPETENCIES

Decision quality

Makes good and timely decisions that keep the organization moving forward. For

example, knows when to act independently and when to escalate issues.

Integrates various inputs, decision criteria, and trade-offs to make effective

decisions. Typically makes good independent decisions.

Drives results

Consistently achieves results, even under tough circumstances. For example,

regularly pushes self to achieve outstanding outcomes; consistently establishes

bold goals for own performance; is passionate about excellent results and

significant contributions. Shows great tenacity to complete goals / initiatives in a

timely way.

Customer focus

Builds strong customer relationships and delivers customer-centric solutions.

For example, probes deeply into customer needs to identify less obvious

interests or expectations. Consistently goes above and beyond to understand

customer requirements and surpass their expectations.

Communicates effectively

Develops and delivers multi-mode communications that convey a clear

understanding of the unique needs of different audiences. For example, listens

attentively and takes an interest. Keeps others well informed; conveys

information clearly, concisely, and professionally when speaking or writing.

Ensures accountability

Holds self and others accountable to meet commitments. For example, accepts

responsibility for own work, both successes and failures. Handles fair share and

does not make excuses for problems. Usually meets commitments to others.

Being resilient

Rebounds from setbacks and adversity when facing difficult situations. For

example, is calm and professional in difficult situations; continues to work

toward objectives. Overcomes obstacles without becoming discouraged; draws

lessons from failures. Recovers from setbacks and adversity.

Interpersonal savvy

Relates openly and comfortably with diverse groups of people. For example,

takes time to build rapport in meetings; speaks about common interests and

priorities; shows tact and sensitivity in difficult interpersonal situations. Maintains

productive relationships with a wide variety of people and from a range of

backgrounds.

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.

Plans and aligns

Plans and prioritizes work to meet commitments aligned with organizational

goals. For example, outlines clear plans that put actions in a logical sequence.

conveys some time frames. Aligns own work with relevant workgroups. Takes

some steps to reduce bottlenecks and speed up the work.

Manages conflict

Handles conflict situations effectively, with a minimum of noise. For example,

disagrees with others in a respectful and tactful manner; handles conflicts and

differences of opinion in a calm, composed manner, rebounds from conflicts

without animosity.

TECHNICAL COMPETENCIES

Data Collection and analysis

Provide technical guidance when required to analyse 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.