Specialist: Claims Technical Advisor / Rejections

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Job Description

Purpose of the Job

Facilitate and mediate an independent process for claim rejection disputes or claims that cannot be resolved through the organisation's 1st line complaints management process

Critical objectives and responsibilities

Facilitate and mediate an independent process for disputes and / or claims

Investigate the complaint by gathering all the relevant facts from the claimant and use any other sources deemed necessary to ensure that decisions are fair, impartial and aligned to the regulatory and / or legislative requirements.

Resolve insurance complaints fairly, efficiently and impartially and not swayed by business pressures.

Acknowledge new disputes timeously.

Conduct root cause analysis of claim rejection disputes and recommend implementation of pro-active prevention measures.

Accountable for maintaining a professional relationship with the Internal Arbitrator and business stakeholders when dealing with complaints and responsible for all communications between the business and the internal arbitrator.

Stay well informed of the Ombudsman’s thinking on emerging consumer issues and ensure that decisions are in-line with industry practices.

Resolve escalated customer queries and complaints in respect of the claim rejection disputes and ensure that timeous feedback is provided to customers and brokers on all matters.

Facilitate and maintain an effective TCF (Treating Customer Fairly) approach to the management of complaints.

Contribute to the maintenance of the complaints reporting and tracking system.

Appropriately escalate complaints to different specialist areas.

Manage complaints end to end, by prioritising according to agreed criteria even if the resolution was finalized in another department.

Track the progression of action plans from claims rejection dispute complaints.

Service delivery to ensure customer satisfaction

Maintain service, quality and desired outputs within the complaints process by ensuring compliance to tactical policies, procedures and standards.

Establish productive operational relationships with key stakeholders in the various channels and administrative teams.

Develop work routines in line with operational plans / schedules in order to manage achievement of service delivery goals.

Share knowledge on, and participate in the creation of new standards, control systems and procedures to maintain service delivery.

Continuous improvement to ensure effective service

Ensure statutory and legislative knowledge is always current in order to resolve customer complaints, to advise the business on corrective solutions to mitigate risks and to improve the customer experience whilst complying with governance requirements.

Ensure adherence to organisational policies, practices and procedures.

Identify solutions to enhance cost effectiveness and increase operational efficiency

Manage quality people practices

Align own behaviour with the organisation culture and values.

Share and transfer process, statutory and legislative knowledge to colleagues.

Collaborate and work with the complaints management team to deliver required service levels.

Actively share information with other team members regarding successes, issues, trends and ideas.

Experience, knowledge & skills required

LLB or equivalent degree.

5 – 8 years’ experience in a complaints management function in the General Insurance Industry.

2 – 3 years’ experience working with the Ombudsman.

Ensures that general insurance claims are handled expeditiously and in a professional manner thereby meeting the customer expectations. Manages the claims function with a team of claims assessors and negotiators. Develops the claims policy, procedures, and practices. Evaluates risks with claims, coverage complexity, and those in excess of field approval limits. Provides counsel regarding claims evaluation and coverage.

Responsibilities

Insurance Claims Evaluation

Investigate the circumstances of complex, high-value claims and the nature and extent of clients' losses. Review and evaluate information gathered using own 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.

Insurance Claims Administration

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

Fraud/Financial Crime Management

Develop and deliver specialized fraud prevention and monitoring activities for an area of operations, in line with the organization's fraud management policies and procedures, to enable the prevention of fraud and enable the initiation of loss mitigations and fraud investigations.

Fraud/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 Systems Development

Research and identify fraud trends and emerging risks, contribute to the drafting of fraud prevention policies and procedures, and identify opportunities for new and/or improved anti-fraud systems functionalities to support the development of fraud/financial crime prevention strategies, policies, procedures, and monitoring systems.

Leadership and Direction

Communicate the local action plan; explain how this relates to the function's strategy and action plan and to the broader organization's mission and vision; motivate people to achieve local business goals.

Work Scheduling and Allocation

Develop short- or medium-term work schedules in order to achieve planned commitments. Approve overtime or use additional resources as needed.

Financial Policies, Guidelines, and Protocols

Develop and deliver financial guidelines and protocols to ensure the company complies with regulations and good financial practice.

Performance Management

Develop and propose own performance objectives; take appropriate actions to ensure achievement of agreed objectives, using the organization's performance management systems to improve personal performance. Or manage and report on team performance; set appropriate performance objectives for direct reports or project/account team members and hold people accountable for achieving them, taking appropriate corrective action where necessary to ensure the achievement of team/personal objectives.

Solutions Analysis

Analyze specific problems and issues to find the best solutions. Solutions could be technical or professional in nature.

Regulatory and Compliance Management

Investigate all kinds of incidents and reports and provide expert advice to more senior colleagues. Minimize risk exposures and ensure adherence with regulatory standards by working with all internal functions to make sure compliance programs are properly implemented.

Organizational Capability Building

Use the organization's formal development framework to identify the team's individual development needs. Plan and implement actions to build their capabilities. Provide training or coaching to others throughout the organization in own area of expertise to enable others to improve performance and fulfill personal potential.

Skills

Action Planning, Claims Management, Data Compilation, Data Controls, Executing Plans, Financial Auditing, Insurance Claims Investigations, Oral Communications, Policies & Procedures, Typology

Competencies

Business Insight

Collaborates

Communicates Effectively

Decision Quality

Directs Work

Ensures Accountability

Financial Acumen

Instills Trust

Education

NQF Level 7 - Degree, Advance Diploma or Postgraduate Certificate or equivalent

Closing Date

13 November 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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JR-73010