Talent Pool: Claims Assessor

Momentum Group Limited

About The Position

Momentum Health, an entity of the Momentum Group, provides integrated health and wellness solutions. The Claims Assessor assesses, reviews and manages living benefit claims in accordance with relevant legislation and company policy, while meeting service-level agreements and client and business expectations. The role assesses disability, dread disease, income disability and other claims requiring medical assessment. It works with internal and external stakeholders to improve assessment quality and clients’ claim experience, supports claims process and system improvements, maintains accurate records, and provides reporting and analysis. The position also contributes to policy and documentation reviews, risk management, client service, continuous improvement and the effective use of company resources.

Requirements

Grade 12 or equivalent qualification (essential).
One to two years’ experience processing claims (essential).
Knowledge of relevant legislation and industry regulations.
Knowledge of the claims assessment process, including paper and EDI claims.
Knowledge of relevant scheme or product rules.
Knowledge of relevant claims operating systems and tools.

Nice To Haves

A relevant degree or qualification.
Experience assessing relevant medical aid claims, using paper and/or EDI.

Responsibilities

Assess, review and manage disability, dread disease, income disability and other claims requiring a medical assessment, in line with service-level agreements.
Collaborate with stakeholders to improve claims assessment and the client claim experience.
Advise on and contribute to procedures and processes in the area of specialisation to improve quality and service.
Maintain accurate records of assessed claims in accordance with business expectations and legislation.
Keep up to date with regulatory frameworks, insurance-related court decisions, and determinations that could affect claims processing or handling.
Identify opportunities for continuous improvement, cost reduction, better-quality claims decisions and systems enhancements.
Provide expertise, assistance and testing support for the development and maintenance of claims systems.
Contribute to and review claims policies, practices, forms and documentation to meet risk-management standards and reflect product and legislative changes.
Provide timely and accurate reporting, analysis and insights on assessed claims when required.
Provide authoritative expertise to clients and stakeholders, and build and maintain relationships with internal and external stakeholders.
Meet service-level agreements and recommend improvements to client service and fair treatment of clients.
Contribute to a culture of rewarding relationships, feedback and exceptional client service.
Maintain collaborative working relationships with peers and stakeholders and participate positively in change initiatives.
Develop professional, industry and legislative knowledge; share and implement new ideas; and take ownership of career development.
Contribute to financial planning, identify ways to improve cost effectiveness and operational efficiency, and manage company resources responsibly.
Provide input into risk identification processes and communicate recommendations through the appropriate forum.