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| POSITION DESCRIPTION | GENERAL INSURANCE INDUSTRY NOVEMBER 2008 |
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Senior Claims Officer - Workers Compensation |
| Position Code: | 4344 | | Career Level: | 3 |
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Responsible for
Providing delivery of superior claims service, determining proper policy coverage to conclude, investigate, evaluate and negotiate assigned cases. |
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Reports To
Claims Supervisor/Team Leader. |
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Supervises
No supervisory responsibilities. |
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Main Activities
Receiving, recording and processing all incoming insurance claims for assigned area.
Interpreting basic policy coverage's and determining if coverage's apply to claims submitted, escalating issues as needed.
Setting reserves and authorising payment within scope of authority, settling claims in the most cost effective manner and ensuring timely issuance of disbursements.
Recognising need for negotiation and participating in planning strategy and negotiating within scope of authority.
Identifying suspicious or potentially fraudulent claims, notifying supervisor, arranging investigation and briefing solicitors if further action is to be taken.
Providing information and feedback on claims activity and developing trends to underwriters/risk assessors to enable appropriate actions to be carried out.
Maintaining current knowledge of insurance guidelines, court decisions impacting claims functions, and policy changes and modifications and recommending changes to Company policies and procedures.
Assisting/preparing files for suit, trial or subrogation and submitting administrative reports as required.
Providing technical expertise and mentoring to assist the development of Junior Claims Officers.
Developing case management plans for clients that stipulate goals and activities.
Encouraging and monitoring client compliance with approved treatment and plans.
Interpreting and actioning medical and financial reports and managing and instructing investigations and implementing findings in terms of the overall strategy.
Developing case management strategies tailored to the needs of individual workers to promote timely treatment and early return to work.
Managing and negotiating cost effective treatment and rehabilitation.
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Key Skills
Broad knowledge of insurance industry and claims processes.
Excellent analytical and negotiation skills.
Strong organisational and written/verbal communication skills.
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Internal Contacts
Claims Department, Underwriting Department, Actuarial Department. |
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External Contacts
Agents, Brokers, Customers, Trustees. |
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Typical Experience
At least 3 years experience in insurance and at least one year of this spent in claims management , together with relevant qualifications. |
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Other Comments
Alternative Title: Case Manager. |
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