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Job Description

End-to-end claim processing including negotiation and settlement of Specialty Lines of Business  claims

Process Specialty lines claims in adherence with SLA.

Arrange assessment in adherence with SLA.

Review merit of claim.

Complete Risk assessment and additional support request analysis.

Clarify and amend information where required

Appoint the support service required.

Review Support Function Report.

Calculate and Analyse technical computations.

Capture all relevant claims updates and decisions on system.

Manage Diarised actions aligned to SOP

Prepare Rejection Letter, where required.

Prepare Payment with communication details.

Await additional information on multiple payments, if required.

Continuously improve claims service, manage claims spend and contain the increase in average cost of claims.

Improve / maintain Specialty Lines  Claims service effectively.

Reduce/ maintain turnaround time of Specialty Lines Claims.

Ensure effective implementation and compliance of claims/ operational systems or procedures.

Ensure diary is maintained.

Ensure estimates are raised accurately and timeously in accordance with best practice as and when new claims and new documents are actioned.

Adhere to Specialty Claims Standard Operations Procedures

Maintain Turn Around Times

Experience , Knowledge & Skills :

·Matric

Appropriate insurance qualification background

Knowledge and interpretation of Specialty Lines  policies

3 years Specialty Lines  claims handling

5 years Commercial Non motor experience specifically Corporate Property, Engineering and Marine

Handles a variety of coverage with a defined loss potential. Reviews and proceses claims of high face value or liability against policies and coverage information. Decision-making is structured and objective. Initiates necessary investigations. Exercises judgment to assign adjusters or to refer information to attorneys or subject-matter experts for additional data. Settles and negotiates claims within authorised authority.

ResponsibilitiesFraud/Financial Crime Investigation

Investigate cases of suspected fraud or financial crime. Identify lines of inquiry, and gather and retain information and physical or electronic evidence to support criminal investigation and/or legal action, engaging specialist investigators or subject-matter experts where necessary. Review the evidence gathered and recommend appropriate action to the organization.

Fraud/Financial Crime Management

Deliver fraud prevention reporting and analysis for a designated area of operations, using financial crime/fraud prevention systems to identify instances, patterns, and trends of suspicious activity, to enable the prevention of fraud and enable the initiation of loss mitigations and fraud investigations.

Insurance Claims Administration

Review and analyze complex insurance claims in line with the organization's standard claims procedures and customer service standards. Initiate investigations and engage independent loss adjusters and/or subject-matter experts where appropriate. Authorize claims within delegated authority and refer unresolved issues or disputes to line manager.

Insurance Claims Evaluation

Investigate the circumstances of claims and the nature and extent of clients' losses. Review and evaluate information gathered using own subject-matter expertise, and examine additional evidence provided by specialist investigators or subject-matter experts to determine the extent of liability. Negotiate settlement of insured losses in line with delegated authority.

Operations Management

Supervise others working within established operational systems.

Document Preparation

Organize and prepare complex documents using a variety of applications for technology devices, such as standard office software. Also responsible for gathering and summarizing data for special reports.

Operational Compliance

Identify, within the team, instances of noncompliance with the organization's policies and procedures and/or relevant regulatory codes and codes of conduct, reporting these instances and escalating issues as appropriate.

Personal Capability Building

Develop own capabilities by participating in assessment and development planning activities as well as formal and informal training and coaching; gain or maintain external professional accreditation, where relevant, to improve performance and fulfill personal potential. Maintain an understanding of relevant technology, external regulation, and industry best practices through ongoing education, attending conferences, and reading specialist media.

Regulatory and Compliance Management

Investigate standard incidents using current regulatory and compliance processes, systems, and procedures, and take action to solve immediate compliance issues. Advise more senior colleagues on more complex problems.

Resolving Customer Issues

Respond to more advanced issue escalations promptly and appropriately; provide managerial approvals as required.

Solutions Analysis

Interpret data and identify possible answers. Involves navigating a wide variety of processes, procedures, and precedents.

Skills

Competencies

Business InsightCollaboratesDecision QualityDrives ResultsFinancial AcumenInstills TrustManages ComplexityOptimizes Work Processes

Education

Closing Date

24 March 2025 , 23:59

The appointment will be made from the designated group in line with the Employment Equity Plan of Old Mutual South Africa and the specific business unit in question.

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