Claims Specialist, Accident And Health

Claims Portfolio

• Attend to all aspects related to a portfolio of claims e.g. new claims, current files, diary, mail, recoveries, Agg Tracker management, third party claims, attorney/investigator matters, settlement within mandate etc.
• Negotiate settlement agreements within mandate.
• Draft settlement agreements.
• Strategically manage a portfolio of claims.
• Appoint and manage loss adjusters and attorneys where warranted.
• Monitor and adhere to service levels in accordance with agreed service level agreements.
• Monitor legal loss adjuster fee expenditure and refer concerns to management within the framework of agreed internal protocol.

Analysis

• Analyse factual and legal issues when assessing claims.
• Critically analyse facts and their impact on the underlying merits assessment as well as the legal aspects of the policy.
• Use judgement in making appropriate decisions on merits and policy response.
• Critically assess and analyse the information required.
• Conduct a strategic assessment of claims and make strategic decisions on handling of claims.
• Have an in-depth understanding of technical and legal aspects impacting on the policy’s operation.

System processing

• Attend to all aspects of system processing relevant to a portfolio of claims e.g. registration of new claims, updating of reserves, cheque requisitions etc.

Client Liaison (Internal and External)

• Respond to queries and resolve to the satisfaction of the affected parties within the scope of authority and / or responsibility.
• Maintain and adhere to service levels
• Prepare for and attend meetings.

General Administration

• Produce reports when required.
• Attend to daily administrative routine tasks in accordance with organisational standards, processes and procedures.
• Attend to the typing of general correspondence if and when necessary.

Qualification and Experience

• Matric
• FAIS compliance (within the required period if not a registered Rep)
• Medical Qualification (if possible)
• Minimum 6 months A&H claims handling experience a preference
• Analysis of medical accounts and medical claims handling a preference
• Assessing medical reports and understanding medical terminology

Knowledge and Skills

• Ability to strategise and drive a claim to finality
• Administrative Skills
• Analysis and Judgement
• Attention to Detail
• Client Orientation 
• Communication Skills including negotiation
• Follow Up
• Initiative
• Interpersonal Skills
• Organisational Awareness
• Planning and Organising
• Teamwork
• Computer Literacy
• Time management and ability to manage multiple claims at the same time
• Attention to detail

Core Competencies

• Being resilient - Contributing dependently
• Collaborates - Contributing dependently
• Cultivates innovation - Contributing dependently
• Customer focus - Contributing dependently
• Drives results - Contributing dependently