Medical Claim jobs

Purpose of the Role

This specialist role reports directly to the Operations Manager: Claims and is responsible for the assessment and administration of Funeral and underwritten claims in line with company policies, regulatory requirements, and service standards.

Key responsibilities include:

• Assess and adjudicate funeral and underwritten claims within agreed service levels
• Request and analyse supporting documentation and medical information where applicable
• Apply policy terms, conditions, and underwriting principles when making claim decisions
• Identify potential fraud indicators and escalate suspicious claims
• Communicate claim outcomes professionally to stakeholders
• Maintain accurate claims records and audit trails
• Collaborate with internal and external stakeholders to resolve complex claims
• Contribute to process improvement initiatives within the Claims

Minimum Requirements

Qualifications

• Grade 12/Matric
• Relevant qualification in Insurance, Business Management, Commerce, or a related field will be advantageous.

Experience

• Minimum of 2-3 years’ experience in claims assessment within the long term Insurance or Financial Services environment.
• Experience in assessing insurance claims and interpreting policy contracts.
• Exposure to regulatory and legislative requirements applicable to the insurance industry.
• Assessor certification/ Nursing or medical background experience

Knowledge

• Claims assessment methodologies and best practices.
• Long Term Insurance policy contract interpretation.
• Policy terms, benefits, exclusions, and conditions.
• Relevant insurance legislation and governance requirements.
• Fraud detection and risk management principles.
• Customer service principles and complaint resolution.
• Medical and health-related information applicable to claims assessment.
• Claims administration systems and associated processes.

Skills

• Strong analytical and investigative skills.
• Sound judgement and decision-making ability.
• Attention to detail and accuracy.
• Effective verbal and written communication skills.
• Problem-solving and conflict-resolution skills.
• Planning, organising and prioritising.
• Stakeholder management and relationship-building.
• Ability to manage confidential and sensitive information.
• Computer literacy and proficiency in relevant systems.

Personal attributes

• Client-centric mindset
• Integrity and professionalism
• Accountability and ownership
• Resilience and ability to perform under pressure
• High level of attention to detail
• Adaptability and willingness to learn
• Collaborative team player.
• Results driven.
• Strong ethical standards.

Overview of Role Responsibilities (Level 1-13)

Insurance Claims Administration - Level 4 - Process Expert
Process assigned straightforward insurance claims, meeting defined customer service standards and ensuring that each claim is supported by valid documentation and supporting evidence. Authorize claims within delegated authority, and refer complex or unresolved issues to senior colleagues.

Insurance Claims Evaluation - Level 4 - Process Expert
Interview and/or visit claimants to evaluate straightforward low-value claims. Determine the value of insured losses in line with the organization's claims policies and the contractual terms of the insurance policy, referring complex or disputed claims to senior colleagues for resolution.

Document Preparation - Level 4 - Process Expert
Prepare moderately complex documents using a variety of applications for technology devices, such as standard office software. Also responsible for gathering and summarizing data for reports.

Operational Compliance - Level 4 - Process Expert
Develop knowledge and understanding of the organization's policies and procedures and of relevant regulatory codes and codes of conduct to ensure own work adheres to those standards. Obtain authorization from a supervisor or manager for any exceptions from mandatory procedure.

Operational Risk Management - Level 4 - Process Expert
Perform in-depth operational risk assessments and develop appropriate mitigation tactics for complex situations.

General Experience

• Minimum of 2-3 years’ experience in claims assessment within the long term Insurance or Financial Services environment.
• Experience in assessing insurance claims and interpreting policy contracts.
• Exposure to regulatory and legislative requirements applicable to the insurance industry.
• Assessor certification/ Nursing or medical background experience
• Sound experience and understanding of straightforward procedures or systems (Minimum 1 year)

Required Skills

Claims Management - Intermediate
Works at an intermediate level to handle individual and portfolios of claims cost effectively, minimizing claims leakage, and meeting organizational and customer claims service standards. Typically works with guidance.

Claims Handling - Intermediate
Works at an intermediate level to use and apply processes and procedures for processing claims by an intermediary. Typically works with guidance.

Claims Settlement - Intermediate
Works at an intermediate level to agree quantum and settle claims, identifying any opportunities for recoveries and its application. Typically works with guidance.

Claims Notification and Investigation - Intermediate
Works at an intermediate level to use and apply the claims notification process, and validate and investigate claims. Typically works with guidance.

Insurance Principles and Practice - Intermediate
Works at an intermediate level to use and apply the core principles of insurance. Typically works with guidance.

Insurance Products and Services - Intermediate
Works at an intermediate level to use and apply the full range of insurance products and services in the market. Typically works with guidance.

Managerial Experience

Not applicable

Education

Required Behavioural Competencies