Claims Assessor (Zestlife)

Were looking for a detail-oriented and client-focused GAP Claims Assessor to join our dynamic this role youll be responsible for assessing and processing GAP short-term insurance claims while delivering a seamless and fair customer experience aligned with Treating Customers Fairly (TCF) principles.

The ideal candidate thrives in a fast-paced deadline-driven environment maintains high levels of accuracy and productivity and is passionate about delivering exceptional service to clients brokers and stakeholders.

This is an exciting opportunity to be part of a high-performing claims team where efficiency accountability and client-centricity are at the heart of everything we do.

• Claims administrative responsibilities in respect of GAP Short Term Insurance Products.
• Ensuring that the principles and outcomes of TCF (Treating Customers Fairly) are practised and achieved in all duties performed and services provided to Zest life customers.

• To adhere to the claims process and guidelines as laid down in terms of TCF and for HealthMax and Profmed
  Medical Aid clients.
• To ensure that you verify and update if necessary the client contact and medical aid information on the
  policy record as per the claim documents submitted.
• To validate all claim documents received and to request any outstanding information from the client or
  broker as a last resort as you need to source the documentation yourself on behalf of the client.
• Capture the claim and ensure all documents are linked to the claim record.
• Capture the claim details as per invoices and medical aid statements once all documents are received.
• Ensure relevant client notes are added to the claim record.
• Ensure only valid claims are paid in accordance with the policy terms and conditions ensure that the policy
  option and commencement date has been considered in determining the validity of the claim.
• Check and ensure policy premiums are up to date and obtain Managements approval if any premium
  offset is required to be recorded.
• To arrange for closed/rejected claims to be reopened or for additional claims to be lodged based on the
  information at your disposal.
• Ensure the client is kept informed and their claim expectation is adequately addressed and managed by
  communicating or interacting timeously and professionally with our clients telephonically and via e-mail with
  the correct template selection and use in your correspondence.
• To identify the fixed discount service providers on a claim and to follow the process and to correctly capture
  the discount verified to reduce the claim payment accordingly.
• To assess a minimum of 9 claims per day with the aim of achieving the target of 11 claims per day.
• To ensure that you attend to process and assess your claims within the TAT of 2 days and any outstanding
  information is requested or obtained.
• To maintain and update your claims and tasks in your To Do List on the system for daily management
  reporting.
• To note all telephone calls made or received on the claim or policy record.
• To meet the minimum 90% QA standard set for a claims assessor and to strive to achieve 100% accuracy.
• To notify the Manager of any priority claims for escalation or complaints received.
• To be pro-active and to assist the clients with their claims by applying the TCF principles.
• Be creative and use your initiative in resolving outstanding documents so that the claim can be processed.
• Think of working smarter and of ways to improve the process to add value to the clients claim experience.
• You are responsible to ensure that you are competent and fully able to assess any Gap or Dental Gap claim
  assigned to you.
• You are responsible to ensure that you consistently achieve the daily weekly and monthly claims productivity
  and accuracy targets.
• You are responsible to ensure that you fully understand the GAP product the claims process and the systems
  so that you can operate efficiently and are competent in your job as a GAP claims assessor.

• Matric
• Computer literacy
• FAIS FIT and proper including RE5
• At least 2 years of experience in short-term or medical health and accident insurance handling.
• At least 2 years of client service experience.
• Good knowledge of the local health industry including the application of ICD-10 and BHF tariff codes
• Knowledge of the OWLS system is advantageous.

• Results and solution-driven
• Strong focus on client centricity and service excellence
• Strong problem-solving and decision-making capabilities
• Analytical with attention to detail
• Resilience and ability to work under pressure
• Effective communication skills and professional client management