Assessor: Medical Claims

Capitec Bank; Bellville; On-site; ZAR 30,000 - 40,000; Full time

Job summary

A leading bank in South Africa is seeking a Medical Claims Assessor to improve claims operational excellence and customer satisfaction. The ideal candidate will have a Health Science degree and 3-5 years of experience in assessing life and disability insurance claims. Core responsibilities include verifying claims, assessing validity, and escalating risks. This position emphasizes stakeholder engagement, with a focus on compliance and quality.

Qualifications

• 3-5 years of experience in assessing life and disability insurance claims.
• Proven experience in stakeholder management and client engagement.
• Understanding of the long-term insurance industry and life and disability claims handling processes.

Responsibilities

• Verify and assess documents for life and disability claims.
• Assess validity of claims and make decisions within turnaround times.
• Identify and escalate risks, including fraudulent claims.

Skills

Administration Skills

Attention to Detail

Decision making skills

Numerical Reasoning skills

Planning, organising and coordination skills

Education

Health Science degree in BSC in Occupational Therapy, Physiotherapy or Nursing

Job description

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 engagement
• Experience in stakeholder management and client engagement

Ideal:

• 3+ years disability claims assessor experience

Knowledge

Minimum:

• Understanding of the long-term insurance industry and life and disability claims handling processes, specifically related to the medical claims landscape
• Strong knowledge of life and disability assessment standards and guidelines
• Comprehensive knowledge and understanding of relevant legal framework relating to life and disability/medical insurance claims
• Investigative tactics, tools and methodologies
• Understanding of the Insurance fraud landscape

Key Performance Areas

Medical Claims Assessment and Oversight

• Verify and assess documents for life and disability claims to ensure they are legally valid
• Assess 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 claims
• Participate 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 agreements

Stakeholder 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 Skills
• Attention to Detail
• Decision making skills
• Numerical Reasoning skills
• Planning, organising and coordination skills

Conditions of Employment

• Clear criminal and credit record

Capitec is committed to diversity and, where feasible, all appointments will support the achievement of our employment equity goals.