Medical Claims Assessor - Individual and Group Life Claims

Location: Johannesburg, South Africa
Salary: R240 000 - R336K
Recruiter: Execuplace Appointments
Job Ref: Medical Claims Asses..
Summary: Claims Assessor/Risk Consultant - Individual & Group Life, Disability, Critical Illness claims exp ess Our client, a dynamic growing Financial Services Provider based in Sandton is seeking to employ a Medical Claims Assessor / Risk Consultant (Individual and Group Life Claims)

 

 

Job Description

Our client, a dynamic Financial Services Provider is seeking to employ a Risk Consultant - Claims Assessor - Group Life & Individual Claims (Disability, Income Disability, Critical Illness) experience essential (2 - 3 years)


Main Purpose of Role

The purpose of this role is responsible to drive the formulation and implementation of the risk model and underwriting philosophy, analyse claims and other data when assessing claims. Providing feedback on all claims, liaising with relevant stakeholders, and utilise their skills, knowledge and experience to make appropriate and accurate decisions on claims worked on. Assessment of income, disability and critical illness claims following policy terms and claims philosophy as well as facilitate case management programmes where applicable to assist claimants in their return to work.

Key Duties and Responsibilities (include but is not limited to):
• Evaluate claims forms and supporting documentation in preparation of making an payment decision
• Gathering information and various types of reports from medical practitioners
• Compare the reports to our client''s existing claims criteria to establish if claim is payable
• Decide on levels of provisions to be raised based on information received
• Writing claims assessment standards/policies
• Auditing/QA of work done by peers
• Deliver claims payment decision
• Determine requirements / documents required to evaluate claims
• Liaise with relevant re-insurers to determine validity of claims and seek their approvals where required
• Explain and communicate final decisions to brokers and clients
• Create schedules for payments and obtain relevant approvals

Additional Skills:
• MS Office and PC literate
• Accurate Typing Skills
• Excellent verbal and written communication skills.

Job Description :
• Quality driven
• Ability to pay attention to detail as accuracy is important
• Using effective interpersonal skills to resolve conflict situations
• Ability to work effectively with others and contribute to team task accomplishment
• Ability to multi-task and manage multiple priorities
• Have the ability to operate effectively under pressure
• Task and deadline orientated
• Analytical mind and above average problem solving techniques
• Strong sense of ownership
• Pro-active and innovative
Qualification:
• Grade 12 (Essential)
• Relevant tertiary qualification; a medical degree preferable
• Minimum 2-3 years experience as a claims assessor
• Experience in both group and life individual life claims (Essential)
• Sound Business and Operational knowledge of Insurance Industry administrative processes
• Good knowledge of the business administration platforms
• Familiar with Compliance Processes and Procedures in the Insurance Industry
• Familiar with the business products and their rules and workings

Attributes:
• Sense of fairness.
• Ability to communicate with personnel of different job descriptions and personality types.
• Personal integrity, confidence and leadership.
• Ability to focus on tasks at hand.
• Sense of order, planning ability.
• Strong personality

 

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