Claims Associate

Roles and Responsibilities

• Manages routine daily claims administration work.
• Coordinates work flow & meets deadlines.
• Evaluates claims with regards to eligibility.
• International Preauthorization.
• Attends calls and e-mails from insurance companies, clients, and providers.
• Makes suggestions to improve service.
• Increases efficiency, minimizes errors, and administration time.
• Coordinates with different departments within the company.
• Reports errors when detected.

Behavioral Requirements

• Strong verbal and written communication skills. Must have the ability to communicate sensitively and effectively with claims department and other departments having regards for the strict need for confidentiality.
• Show flexibility, excellent interpersonal skills.
• Team Player.
• Knowledge of overall insurance industry practices is a plus; the ability to exercise initiatives and be able to work flexibly under pressure and to tight deadlines.
• Experience of working with senior managers and understanding the necessity to act in a pleasant and courteous manner and to be able to work effectively with others.
• To be capable of responding diplomatically to pressures and problems showing a calm approach to working towards deadlines and always able to show an innovative and creative approach to work.
• Ability to work well with all levels of internal management and staff, as well as outside clients and users.
• Flexible and ability to work shifts.

Behavioral Competency

Customer & Market Excellence:

• Strive for excellence at every touch point with the customer.
• Foster state-of-art technical/operational knowledge and strive for continuous simplification.
• Be the benchmark.

Collaborative Leadership:

• Empower the team and provide purpose and direction.
• Develop people, provide feedback, and care for employee wellbeing.
• Collaborate and exchange best practice.

Entrepreneurship:

• Act on opportunities, anticipate trends, take risks, and promote a culture that allows for honest failure.
• Take ownership and responsibility.
• Embrace innovation and a culture that allows making decisions without fear of retribution.

Trust:

• Act with integrity, honor commitments, tell the truth.
• Foster diversity and inclusiveness.

Act transparently and promote corporate social responsibility.

Minimum Requirements

• Bachelor’s degree (Nursing) with at least 2 years of clinical experience.
• 3+ years claims processing experience in an Insurance / TPA environment. A must to have coding experience.
• Physically fit to carry out duties.
• Legally permitted to work in the country of operations.
• Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

Desired Candidate Profile

A Claims Assessor is a professional who evaluates and processes claims made by policyholders in the insurance industry. Their primary role is to assess the validity of claims, determine the extent of the insurer's liability, and ensure that compensation is provided in a fair and timely manner, according to the terms of the insurance policy. Claims assessors work across a variety of insurance sectors, including life, health, property, casualty, and auto insurance, and they typically liaise with claimants, insurers, and other professionals (like medical experts or investigators) to gather the necessary information to make an informed decision.

Key Responsibilities of a Claims Assessor:

1. Claims Evaluation:

   • Assess Claim Validity: Review and evaluate claims submitted by policyholders to determine if they meet the terms and conditions of the insurance policy.
   • Investigate Claims: Investigate the circumstances surrounding a claim, including interviewing claimants, witnesses, and involved parties. Verify the authenticity of claims to detect potential fraud.
   • Evaluate Damages or Losses: Assess the extent of the damage, loss, or injury involved in the claim, using documents, medical reports, photos, or third-party reports to determine the appropriate level of compensation.

2. Decision Making:

   • Determine Liability: Establish whether the insurer is liable to pay the claim based on policy coverage and the specifics of the incident or event.
   • Policy Interpretation: Interpret the terms of the insurance policy, including exclusions, coverage limits, and endorsements, to make an informed decision on claim settlements.
   • Approve or Deny Claims: Approve claims that are deemed valid and in compliance with policy terms. Deny or offer reduced settlements for claims that do not meet the policy criteria or are deemed fraudulent.

3. Claims Processing:

   • Documentation and Record Keeping: Maintain detailed records of all claims, investigations, assessments, decisions, and settlements in compliance with regulatory requirements and company policies.
   • Communication: Communicate decisions and updates clearly with claimants, brokers, and agents. This includes explaining reasons for claim denials, advising on the next steps, and offering assistance with the claims process.
   • Processing Settlements: Facilitate the settlement process, ensuring that the claimant receives the correct payout within the timeframe specified in the policy. This could involve issuing checks or coordinating with other parties for payments.

4. Collaboration and Liaison:

   • Coordinate with Medical Professionals or Experts: In cases involving health, life, or disability claims, liaise with doctors, medical professionals, or loss adjusters to assess medical reports and verify claims.
   • Work with Adjusters and Investigators: Collaborate with claims adjusters, legal teams, and fraud investigators to gather additional information and make accurate claim determinations.
   • Coordinate with Legal Teams: For claims involving potential legal disputes or lawsuits, work with the legal team to ensure that claims are processed in accordance with regulatory requirements and legal standards.