Talent Pool: Claims Administrator

Momentum Metropolitan Holdings Limited; Sandton; On-site; ZAR 180,000 - 320,000; Full time

Job summary

Momentum Metropolitan Holdings Limited is seeking a Claims Processing Specialist to review and manage disability and related insurance claims within set SLAs. You will assess documentation, collaborate with internal teams, and ensure accurate record-keeping and compliance with regulatory guidelines.

The role requires strong communication skills, familiarity with paper-based and EDI claim methods, and knowledge of claims operating systems. Training and ongoing development are provided.

Qualifications

• Mandatory Grade 12 certificate and relevant higher education qualifications.
• Bachelor's degree in a related field preferred.
• Experience or training in claims processing is advantageous.

Responsibilities

• Process disability, dread disease, and income disability claims within SLA.
• Collaborate with stakeholders to improve claims assessment.
• Maintain accurate records and ensure compliance with regulations.
• Provide reporting and insights on assessed claims.
• Stay updated on regulatory frameworks affecting claims processing.

Skills

Communication skills

EDI systems knowledge

Claims processing

Regulatory awareness

Data privacy understanding

Education

National Senior Certificate / Grade 12

Bachelor's degree in business administration / insurance / finance

Tools

EDI

Claims operating systems

Job description

Through our client-facing brands Momentum Group, with Multiply (wellness and rewards programme), and our other specialist brands, including Guardrisk and Eris Property Group, the group enables business and people from all walks of life to achieve their financial goals and life aspirations. We help people grow their savings, protect what matters to them and invest for the future. We help companies and organisations care for and reward their employees and members.

Role Purpose

To effectively review, process and manage benefit claims within service level agreements and according to company policies and procedures.

Requirements

• National Senior Certificate / Grade 12 Certificate - (Essential)
• A bachelor's degree or equivalent qualification in a relevant field such as business administration, insurance, finance, or a related discipline - (Desirable).
• Scheme rules and regulations training - (Desirable)
• Benefits training - (Desirable)
• Claims training - (Desirable)
• 1-2 years of experience in claims processing or a similar field,
• Experience in assessing relevant insurance or medical aid claims, ideally with proficiency in both paper-based and Electronic Data
• Interchange (EDI) methods - (Desirable).
• A comprehensive understanding of the legal and regulatory frameworks governing claims administration (e.g., knowledge of insurance laws, data privacy regulations, claims handling guidelines, and any other applicable legislation).
• Knowledge in both traditional paper-based claims assessment processes and electronic data interchange (EDI) systems.
• Knowledge in utilising claims operating systems and tools (i.e, industry-standard claims management software, databases, and other technological tools used in processing and documenting claims).
• Familiarity with the specific scheme or product rules governing the claims being processed (e.g., understanding the coverage, exclusions, limitations, and other relevant provisions specific to the insurance product or scheme being administered).
• A basic understanding of medical terminology, conditions, and assessments related to the claims being processed.
• Communication skills (written and verbal)

Duties & Responsibilities

Process

• Process and assess disability, dread disease, income disability claims, and other medically assessed claims in accordance with service level agreements, ensuring accurate and efficient claim processing.
• Collaborate and partner with relevant stakeholders to enhance the claims assessment process and improve the client's claim experience.
• Advise on and contribute to the development of procedures and processes within the specialised area to drive continuous quality improvement and service enhancement in claims processing.
• Maintain accurate records of all assessed claims, aligning with business expectations and relevant legislation, to ensure comprehensive documentation and accountability.
• Stay updated on relevant regulatory frameworks, insurance-related court decisions, and determinations by regulatory bodies, ensuring compliance in claims processing and handling.
• Identify opportunities for continuous improvement, cost reduction, and quality enhancement in claims decisions, as well as system enhancements, to optimise overall efficiency.
• Provide insights, knowledge, assistance, and testing support as necessary for the development and maintenance of claims systems, aiming for improved quality, accuracy, and efficiency.
• Contribute to the review and alignment of claims policies, practices, forms, and documentation with risk management standards, product changes, and legislative updates, ensuring compliance and best practices.
• Deliver accurate and timely reporting, analysis, and insights on assessed claims, providing valuable information for decision-making and operational efficiency.

CLIENT

• Provide authoritative expertise to clients and stakeholders, offering professional guidance and support in claims assessment and processing.
• Build and cultivate strong relationships with clients, as well as internal and external stakeholders, fostering trust and effective collaboration.
• Ensure delivery on service level agreements made with clients and stakeholders, proactively managing client expectations and addressing any concerns or issues.
• Make recommendations to improve client service and ensure fair treatment of clients within your area of responsibility, striving for exceptional customer satisfaction.
• Actively participate in and contribute to a culture that fosters rewarding relationships, facilitates feedback, and provides exceptional client service, promoting a positive and customer-centric work environment.

PEOPLE

• Foster productive and collaborative working relationships with peers and stakeholders, promoting teamwork and knowledge sharing.
• Positively influence and actively participate in change initiatives, embracing and driving positive transformations in the workplace.
• Continuously develop professional expertise in terms of industry knowledge, legislation, and professional skills, staying abreast of advancements and best practices.
• Contribute to continuous innovation through the development, sharing, and implementation of new ideas, fostering a culture of creativity and improvement.
• Take ownership of driving personal career development, seeking opportunities for growth and learning to enhance professional capabilities.

FINANCE

• Contribute to the financial planning process within your area of responsibility, providing input and insights to support effective financial management.