Assess and adjudicate Life and Medical claims within authority limits in accordance with policy terms and conditions.
Conduct claims investigations where necessary, including reviewing medical evidence, policy documentation, and other relevant information to determine claim validity.
Identify, investigate, and escalate complex claims to the Claims Manager for further review.
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The successful candidate will manage enquiries and escalations from TPAs and internal stakeholders, providing prompt and professional responses. Candidates should possess a Diploma or Degree in Business, Insurance, Healthcare Administration, or a related field. Experience in employee benefits or medical claims, a good understanding of employee benefits and medical insurance policies, strong organisational skills, the ability to manage multiple priorities independently, and proficiency in Microsoft Office applications, particularly Excel, will be advantageous.
Assess, negotiate, and settle WICA claims in accordance with policy terms and conditions, within delegated authority limits and prescribed timelines.
Ensure claims handling complies with WICA regulations, internal policies, and stipulated timelines, while maintaining effective cost control through appropriate reserving and claims strategies.
Review claim documentation, including medical reports, accident reports, and supporting documents, to determine liability and compensation.
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