Kgabo Thlaku
Claim Assessor
Centurion,GP
Summary
Competent, diligent, and self-motivated Claims Assessor with extensive knowledge in assessments of life, disability, Critical illness, income protection, hospital cash and credit life claims. Resourceful team player who can function effectively under pressure and yet accomplish team objectives. Skilled at interpreting policy wordings and making fair and consistent claim decisions.
Overview
14
14
years of professional experience
Work History
1. Claims Assessor
Reinsurance Group Of America
07.2022 - Current
- Effective claims management of group ad individual death, critical illness, disability, income protection, hospital cash, retrenchments, funeral, credit life claims.
- Identifying possible fraud, nondisclosures and pre-existing health conditions.
- Maintained accurate records of all claims assessed, facilitating easy retrieval when needed for audits or internal quality assurance reviews.
- Improved claim processing accuracy by implementing a meticulous claim assessments and conducting thorough investigations.
- Discuss complex cases with relevant stakeholder where policy wording is not clear or vague to ensure fair and consistent claim decision.
- Organize claims training sessions.
- Attend to internal and external client queries in line with the service level agreements.
- Analyse the claims experience of different client portfolios and provide feedback to the relevant business development actuaries.
- Attend industry events and maintain relationships with different stakeholders.
- Identify cases that require case management and facilitate the return-to-work process.
- Escalated complex claims to senior management for further review, ensuring a collaborative approach to decision-making and fair outcomes.
2. Claims Assessor
Hannover Reassurance South Africa
07.2017 - 06.2022
- Effective claims management of both group and individual death, critical illness, disability, income protection, funeral, credit life claims.
- Synopsising claim documents on the claim’s system and complete all the required fields for monthly reporting purposes.
- Identify possible non disclosure, pre-existing health conditions and fraudulent claims with comprehensive investigations and minimizing company losses .
- Promptly discuss complex claim decisions with assessors from the direct insurers.
- Discuss complex cases with relevant stakeholders to ensure that claim outcome are fair and consistent.
- Analyze the claims experience of different client portfolios and provide feedback to the relevant portfolio managers.
- Coaching and mentoring new claims recruits
- Assist business developments with the development of new insurance products.
- Provided ongoing support to Assessors from the direct insurer through on the job training and formal training sessions to ensure skill transfer.
3. Disability Claims Assessor
3. Disability Claims Assessor
10.2013 - 06.2017
- Ensure effective claims management of group products i.e. PHI, Lump sum Disability, and Critical Illness claims.
- Identify claims that are appropriate for case management and ensure effective case management and return to work.
- Ensure service level agreements are always met.
- Manage and maintain relationships with different stakeholders.
- Compile monthly claims reporting spreadsheets.
- Train group HR officers, benefit administrators and brokers.
- Adhere to policies and procedures at all times.
4. Occupational Therapist
Gail Vlok Associates
06.2013 - 09.2013
- Assess road-accident fund clients.
- Compile medico-legal reports for road-accident fund clients.
- Attend monthly team meetings.
5. Occupational Therapist
FH Odendaal Hospital
01.2010 - 05.2013
- Identify, assess, and treat clients who could benefit from Occupational Therapy services.
- Improved patient outcomes by implementing individualized treatment plans and monitoring progress.
- Compile medical reports for children who need special schools and reasonable accommodations in mainstream schools.
- Collaborated with interdisciplinary team members for comprehensive patient care and optimal results.
- Enhanced patient functional ability through evidence-based therapeutic interventions and exercises.
- Supervise Occupational Therapy Assistants and Occupational therapy technicians.
- Compile monthly reports.
Education
Claims Assessor Course -
University of Cape Town
04.2001 -
Bsc. Occupational Therapy -
University of The Witwatersrand
04.2001 -
Skills
Policy wording Interpretation
Policy validation
Microsoft Office skills
Claims data analysis
Proactive and Problem-solving abilities
Teamwork and Collaboration
Analytical Thinking
Effective Communication
Timeline
1. Claims Assessor
Reinsurance Group Of America
07.2022 - Current
2. Claims Assessor
Hannover Reassurance South Africa
07.2017 - 06.2022
3. Disability Claims Assessor
3. Disability Claims Assessor
10.2013 - 06.2017
4. Occupational Therapist
Gail Vlok Associates
06.2013 - 09.2013
5. Occupational Therapist
FH Odendaal Hospital
01.2010 - 05.2013
Claims Assessor Course -
University of Cape Town
04.2001 -
Bsc. Occupational Therapy -
University of The Witwatersrand
04.2001 -