JOB PURPOSE
Deliver and support sound quality of claims decision making, prevent fraud and
manage expenditure through the validation of claims by using expert abilities in
various fields of investigation.RESPONSIBILITIES
Needs AssessmentExplore issues or needs, establishing potential causes and barriers as well as
related issues. Validate claims by investigating, applying expertise, utilizing
resources (e.g. police, supplier etc.) and interviewing customers as well as other
parties.
Analyze specific problems and issues to find the best solutions. Solutions could be technical or professional in nature.
Data Collection & Analysis
Ask questions, collect data from a variety of sources, analyse information and
investigate claim. Ensure effective costing of claimed items through ensuring
professional, thorough investigation of claims.
Make decisions according to established criteria to ensure standardization
across the organisation by accurately administrating and underwriting claims.
Use appropriate tools (ITC, supplier contract and/or negotiation) to accurately
cost applicable claims on a day to day basis.
Customer Service
Provide a quality service to customers while identifying opportunities to secure
new business or support retention. Responsibilities may include processing
cases, dealing with complex queries and investigating and resolving customer
problems.
Uphold agreed service level agreements (set turnaround times) and ensuring
customer satisfaction and retention.
Stakeholder Engagement
Effectively build, maintain and manage relationships with service providers and
suppliers, colleagues, internal and external customers.
Work Scheduling and Operational Compliance
Contribute to optimize work practices and procedures by maintaining an
acceptable workload in order to get the job done, coordinating with support
services.
Ensure claims are finalized within the set parameters (turnaround time, terms
and conditions applied accurately).
Administration
Produce, update and provide best practice support to customers on the claims
administration process and other departmental systems, in line with claims
policy, rules and SLAs.
Ensure accurate administration and underwriting of claims.
Maintain an acceptable claims expenditure
ratio by finalizing and adjusting claims accurately.
Compliance
Identify shortcomings in compliance processes, systems and procedures, and
develop ad hoc solutions to problems within an assigned unit or discipline.
Up-Sell Customer Propositions
Identify a selection of products or services that may meet the customer's
requirements, explain the product/service features influence the customer to add
additional cover.
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.
Remain up to date with current and new quality standards and product
knowledge to enable effective decision making.TECHNICAL COMPETENCIES
Investigative KnowledgeApply concepts of knowledge / skill and able to provide guidance when required.
Forensic investigating knowledge.; Investigation procedures and techniques
(e.g. paper cars / hidden numbers etc.)..
Policy and procedures
Provide technical guidance when required to develop, monitor, interpret and
understand policies and procedures, while making sure they match
organizational strategies and objectives.
Short term insurance industry knowledge.
Verbal and Written Communication
Use clear and effective verbal communication skill and provide technical
guidance when required to express ideas, request actions and formulate plans
or policies.
Policy and Regulation
Interpret and apply knowledge of laws, regulations and policies in area of
expertise.
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.
Numerical SkillsUse an understanding of numerical concepts to perform mathematical
operations such financial and numerical data.
Computer skills
Support business processes by understanding and effectively using standard
office equipment and standard software packages.
Proficient in MS Office.
Presentation skills
Communicate with other people by speaking in a clear, concise and compelling
manner.
Negotiation
Negotiate to help the organization by obtaining consensus between two or more
internal or external parties who may have different interests.
Risk Management
Identify, assess, prioritize and manage risks in a production process.
Data Collection and analysis
Analyze information and data trends for use in reports to help guide decision
making.
Health and Safety
Manage and apply safe systems of work with guidance.EDUCATION
General EducationGrade 12/ SAQA Accredited Equivalent (Essential);
Regulatory Examination (Essential); Science (Mechanical / Physical),
Mathematics and African Language (Advantageous); Forensic Investigation
Diploma / Insurance Institute qualification (Advantageous)
EXPERIENCE General Experience
5 or more years work experience in any investigative work OR 2 or more years
work experience within one or more of the following fields: insurance / police /
forensic / audit / legal (Essential)
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