Overview
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Purpose Statement
To improve claims operational excellence, increase customer satisfaction, minimize losses for Capitec Insurance through accurate and holistic assessment of life and disability claims, in accordance with terms and conditions of the respective policy / ies, legislative frameworks and goals, objectives, processes and standards sets by Capitec.
Location : Century City
Qualifications
A Health Science degree in BSC in Occupational Therapy, BSC in Physiotherapy or BSC in Nursing (Registered Nurse)Experience
Minimum :
3-5 years’ experience in assessing life and disability insurance claims in the long-term insurance environment with proven experience in stakeholder management and client engagementExperience in stakeholder management and client engagementIdeal :
3+ years disability claims assessor experienceKnowledge
Minimum :
Understanding of the long-term insurance industry and life and disability claims handling processes, specifically related to the medical claims landscapeStrong knowledge of life and disability assessment standards and guidelinesComprehensive knowledge and understanding of relevant legal framework relating to life and disability / medical insurance claimsInvestigative tactics, tools and methodologiesUnderstanding of the Insurance fraud landscapeKey Performance Areas
Medical Claims Assessment and Oversight
Verify and assess documents for life and disability claims to ensure they are legally validAssess the validity of life and disability claims accurately and holistically and make a decision within the agreed turnaround times, maintaining high standards of quality and consistently meeting or exceeding productivity standards and set targets and in accordance with the terms and conditions of the policy, legislative frameworks, claims frameworks, claims process and procedure, authority limits, goals and objectives and any standards sets by Capitec Insurance.Identify and escalate risks, including fraudulent claims, in line with Capitec’s Fraud Prevention and Identification Framework.Identify trends and areas of concern and escalate accordingly.Plan and execute to ensure that all the required checks on claims are executed, with a specific focus on early claimsParticipate in the analysis of results and provision of statistics that will inform managerial decision making.Process claims within the pre-determined time limits.Medical Claims Queries and Complaints
Respond and resolve claims queries and complaints within service level agreementsStakeholder engagement
Build trusting relationships with internal and external stakeholders to achieve Capitec Life objectives.Educate stakeholders on their responsibilities regarding the Claims Assessment Framework.Provide effective, efficient, and professional service to all customers through their preferred channels.Liaise with third parties to gain additional facts and information about the respective event.Skills
Administration SkillsAttention to DetailDecision making skillsNumerical Reasoning skillsPlanning, organising and coordination skillsConditions of Employment
Clear criminal and credit recordCapitec is committed to diversity and, where feasible, all appointments will support the achievement of our employment equity goals.
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