Senior Claims Specialist Mmh251002-2

Guardrisk; Gauteng; On-site; ZAR 750 000 - 1 000 000; Full time

Job summary

A leading insurance provider in South Africa seeks a Claims Manager with expertise in strategic oversight and fraud detection. This role requires 7–10 years of experience in claims management within the insurance sector. The successful candidate will develop claims frameworks, align policies with organizational strategy, and mentor teams, ensuring high-quality claims experiences across African markets.

Qualifications

• 7–10 years of experience in insurance operations focusing on claims management.
• Experience in fraud detection and forensic reviews.
• Demonstrated ability to influence senior stakeholders.

Responsibilities

• Develop a business unit level claims framework and governance model.
• Align claims policies with product and underwriting.
• Mentor in-country assessors on claims philosophy and client empathy.

Skills

Strategic oversight

Claims management

Fraud detection

Client empathy

Analytical skills

Education

Degree in Insurance and Risk Management

Tools

Claims systems

Workflow tools

Job description

Role Purpose

To provide strategic oversight, deep technical claims expertise, and process innovation across Africa Life's end-to-end claims process. The role ensures consistent, integrated, and high-quality claims experiences across markets by aligning operations to product intent, underwriting, finance, and customer service.

This role brings a strategic, risk-focused, and client‑centred lens to a critical value chain function and establishes a clear claims philosophy and principles across Africa Life, ensuring claims practices are not only efficient but consistent, fair, and aligned to business strategy and client trust.

Requirements

• Degree in Insurance and Risk Management, Law, Business or related field (essential)
• Claims, fraud, or forensic investigation certifications (desirable)
• Training in operational risk or process improvement (desirable)
• 7–10 years of progressive experience in insurance operations, with a strong focus on claims management and strategy
• Proven track record in leading or overseeing claims functions across multiple product lines
• Experience in fraud detection, forensic reviews, and claims risk management, ideally with exposure to African market dynamics
• Direct involvement in claims integration with underwriting, finance, actuarial, and product development functions to ensure alignment across the value chain
• Background in designing or implementing group‑level claims frameworks, policies, or governance standards
• Experience in analysing large claims data sets to identify trends, cost drivers, and opportunities for strategic intervention
• Exposure to cross‑country operations, managing or advising on claims practices in multiple jurisdictions
• Hands‑on experience with claims systems and workflow tools (e.g., administration platforms, fraud detection systems, CRM or case management systems)
• Leadership or mentoring of claims teams or assessor groups, including capability building and training
• Experience working in regulatory and compliance‑heavy environments
• Demonstrated ability to influence without authority, shaping operational improvements and governance by engaging senior stakeholders across functions
• Experience applying business analysis techniques to claims contexts – requirements gathering, process mapping, and solution design
• End‑to‑end claims lifecycle and processing systems
• Product design, benefit rules, and underwriting principles
• Fraud detection strategies and techniques
• Life insurance regulatory frameworks in African markets
• Claims accounting, provisioning, and reconciliations
• Cross‑functional integration with service, finance, and reinsurance
• Understanding of medical conditions and disability assessments, ideally with a background or exposure to clinical or allied health professions

Duties and Responsibilities

Key Outputs

PROCESS

• Develop a business unit level claims framework and governance model.
• Lead claims analytics and deep dives into fraud trends and anomalies.
• Align claims policies and processes with product, underwriting and finance.
• Design and optimise claims workflows and handovers between countries and functions.
• Define and monitor claims‑related KPIs, SLAs, and operational benchmarks.
• Use claims experience insights to recommend upstream changes to product design, underwriting practices, and policy administration systems, ensuring alignment with risk appetite and reducing claim friction.
• Partner with actuarial and reinsurance to refine agreements based on emerging claims trends and risk behaviours.
• Develop and embed a group‑wide claims philosophy and best practices, ensuring alignment across countries.
• Assess the impact of claims practices on policyholder behaviour, including retention and lapse rates, and recommend interventions.
• Act as the escalation point for complex or disputed claims from in‑country assessors, providing guidance and final decisions where required.

CLIENT

• Shape claims experience strategy to balance customer empathy with business risk.
• Analyse complaints and claims turnaround data to identify improvements.
• Collaborate with service and product teams to improve communication and transparency in the claims process.
• Escalate issues from claims trends to distribution and sales teams, ensuring that customer disclosures, training, and scripts accurately reflect product intent and reduce disputes.
• Drive end‑to‑end improvements across the value chain by linking claims feedback to upstream functions, enhancing overall customer experience and trust.

FINANCE

• Identify and prevent claims leakage and inappropriate payouts.
• Support claims provisioning and reconciliations.
• Partner with finance on claims reserve adequacy and recoveries.

PEOPLE

• Enable in‑country claims teams through training, standards and technical support.
• Mentor and coach in‑country assessors, not only on process but also on professional judgement, claims philosophy, and client empathy.
• Share best practices and promote a culture of fairness, risk awareness and continuous improvement.
• Act as a subject matter expert to cross‑functional teams.