Group Claims Assessor

Group Claims Assessor

Detail-oriented and empathetic Claims Professional with 2–3+ years’ experience in group risk and high-volume claims environments. Skilled in end-to-end claims assessment, policy interpretation, fraud detection, and regulatory compliance. Committed to balancing efficiency, accuracy, and compassionate client service while upholding the highest ethical standards.

Key Responsibilities & Capabilities

• Conduct full end-to-end assessment of group life claims in line with policy terms, exclusions, and conditions.
• Accurately calculate claim benefits and provide approval/rejection recommendations within delegated authority limits.
• Process claims within strict SLA timeframes while maintaining near-zero error rates.
• Provide clear, empathetic communication to claimants, beneficiaries, and HR representatives during sensitive circumstances.
• Explain documentation requirements, claims procedures, and decisions transparently and professionally.
• Identify, investigate, and escalate suspicious or potentially fraudulent claims with supporting evidence.
• Ensure compliance with:
  • Financial Sector Conduct Authority (FSCA)
  • Protection of Personal Information Act (POPIA)
  • Guardrisk
  • Gen Re
  • Internal policies and Treating Customers Fairly (TCF) principles
• Maintain complete, auditable claims records and documentation.
• Liaise with Finance, Underwriting, Compliance, and reinsurers to ensure seamless resolution.

Core Competencies

• Claims assessment & policy interpretation
• Group risk benefits
• Fraud detection & escalation
• Regulatory compliance
• SLA management
• Stakeholder communication
• Emotional intelligence & resilience
• Ethical decision-making

Technical Skills

• Claims management systems
• Microsoft Office Suite
• Insurance principles & policy wordings
• Regulatory frameworks (FSCA, TCF, POPIA)
• Accurate benefit calculations

Qualifications

• Matric (Grade 12)
• Diploma/Degree in Insurance, Finance, or related field (advantageous)
• FAIS compliance or relevant insurance certifications (advantageous)
• Clear credit and criminal record

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