Financial advisor
Mbali Ackerman
Claims Assessor
Johannesburg
Summary
I'm a Detail-oriented Claims Assessor with ten years of experience in corporate insurance claims. Strong command of claimant information intake processes, records documentation and fraudulent investigation protocols. Impactful skills preparing operational reports, presenting findings to senior management and motivating claim payouts.
Overview
11
11
years of professional experience
4
4
Languages
Work History
CLAIMS ASSESSOR
SIRAGO UMA
Johannesburg
05.2023 - Current
- Hospital/medical claims assessing by taking pre-existing conditions into consideration
- Assessing of GP and specialist accounts and making payments
- Process claim administration
- Take claim details, issue forms and check that policy covers the claim and premiums are up to date
- Handling new claims from new registration, following up on progress and keeping the broker/ client informed of progress
- Checking for any outstanding balances on the proforma invoice before processing the claim.
- Consulted police and hospital records when needed.
- Handled complaints and grievances using negotiating and problem-solving skills.
- Researched claims and incident information to deliver solutions and resolve problems.
- Identified insurance coverage limitations with thorough examinations of claims documentation and related records.
- Read over insurance policies to ascertain levels of coverage and determine whether claims would receive approvals or denials.
- Conducted day-to-day administrative tasks to maintain information files and process paperwork
- Interviewed agents and claimants to correct errors or omissions and investigate questionable claims.
- Maintained suspicious claims database and prepared reports for supervisors.
- Delivered exceptional customer service to policyholders by communicating important information and patiently listening to issues.
- Examined claims forms and other records to determine insurance coverage.
- Followed up with insured individuals regarding premium and deductibles payments.
CUSTOMER SERVICE CONSULTANT
SIRAGO UNDERWRITING MANAGERS
Johannesburg
10.2021 - 04.2023
- Providing telephonic and email support to the intermediary on record, authorised representatives & policyholders, confirming policy benefits & processes
- Attending to claims queries and follow ups; premium confirmations, policy amendments (update banking details, member swap) & cancellations
- Escalate claims and adhere to TAT
- Liaising with all departments on behalf of brokers and clients for enquiries.
CLAIMS ASSESSOR
AMBLEDOWN FINANCIAL SERVICES
12.2021 - 04.2022
- Access claims daily by logging into the administration system
- Worked within the claims turnaround time
- Ensured that the submitted documentation is clear and authentic
- Verify the Life assured and claimant through checking the details on the relevant Systems as well as against the client’s application form and Policy documents
- Ensured every claim is assessed in accordance with the relevant policy terms and conditions
- Contacted the relevant third parties for required information (e.g., Police, medical personnel, medical aids, employers, clinics, hospitals, etc.)
- Identified suspicious claims and referred to the forensic investigator for further investigation
- Responsible to make decisions (approve or repudiate) on each claim and motivated these decisions
- Drafted repudiation letters and responded to complaints timeously via email or telephonically
- Referred claims to the ex-gratia committee with a motivation where claimants request under exceptional circumstances
- Where applicable refer claims to unclaimed benefits.
CLAIM ADMINISTRATOR
AFRICAN BANK
01.2013 - 10.2020
- Receive a list of new claims daily from Collections – Insurance Collection
- Sort claims into various categories – Death, Short-time, Lay-Off, Temporary and Permanent Disability
- Handling claims from registration, assessment to settlement
- Reporting and handling of claims
- Communicate with clients, the responsible party, solicitors, and various other parties involved in the claims process, by telephone and/or by written communication
- Ensure effective and timely claims management and settlement (in line with the SLA agreement)
- Assist with administrative functions and undertake special projects as and when requested
- To update client on the progress of the claim telephonically and via email
- Advise clients on general queries and claims issues
- Handling of Compliments and Complaints according to the Compliments and Complaints Business Processes.
Education
Wits Plus Corporate Communication Certificate (CPTS0068) - undefined
Higher Certificate in Investment Administration NQL 5 – 120 credits - undefined
Regulatory Examination for Representatives (RE 5) - undefined
COB 1 Short Term Insurance: Personal Lines - undefined
COB 3 Long Term Insurance - undefined
Certificate - Critical Thinking For Claims Assessors
Udemy
Johannesburg 02.2024 - 02.2024
Skills
Good Telephone EtiquetteCritical & Analytical SkillsAdapting and responding to change
Policy investigations
Policy investigations
Underwriting knowledge
Claims
Healthcare Common Procedures Coding System (HCPCS)
Insurance policy coverage knowledge
Microsoft Office Suite
Other Course Modules
GAP Medical Insurance Product Knowledge
Personal Information
Date of Birth: 09/14/90
References
- Ms. Sheinel Naidoo, Sirago Underwriting Managers, Quality Assurance Manager, 079 666 4087, sheinelN@sirago.co.za
- Mrs. Julie Mohammed, Ambledown Financial Services, Unlimited claims Supervisor, 082460 5553, Julie@ambledown.co.za
- Mrs. Carol Hlalele, African bank, Credit Life Manager, 0711932433, clekoane@africanbank.co.za
Interests
Timeline
Certificate - Critical Thinking For Claims Assessors
Udemy
02.2024 - 02.2024
CLAIMS ASSESSOR
SIRAGO UMA
05.2023 - Current
CLAIMS ASSESSOR
AMBLEDOWN FINANCIAL SERVICES
12.2021 - 04.2022
CUSTOMER SERVICE CONSULTANT
SIRAGO UNDERWRITING MANAGERS
10.2021 - 04.2023
CLAIM ADMINISTRATOR
AFRICAN BANK
01.2013 - 10.2020