Specialist Administrator : Claims Approval

Overview: * The Specialist: Claims Approval is responsible for reviewing, analysing and verifying claims-related information, applying specialist knowledge and expertise to ensure accurate, efficient and compliant claims processing. * The role requires strong analytical and problem-solving skills to identify trends, improve processes and enhance customer satisfaction. This includes analysing data, compiling reports and recommending practical and innovative solutions to operational challenges. * The successful candidate must be able to engage with team members and relevant stakeholders, understand business challenges and use their technical knowledge and experience to troubleshoot issues and resolve them efficiently. * The role also involves investigating and managing improper payments, addressing Pension Funds Adjudicator PFA related matters and ensuring that claims are handled accurately and in accordance with relevant legislation, fund rules and internal procedures. Key Responsibilites: Claims Processing, Quality Assurance and Compliance * Uphold Coordinate and monitor the end-to-end claims processing cycle, ensuring that all claims, enquiries and complaints, including those received from the Pension Funds Adjudicator PFA and Financial Sector Conduct Authority FSCA, are managed in accordance with applicable policies, procedures and service level agreements SLAs. * Ensure all claims are quality-assured and processed accurately in accordance with relevant legislation, fund rules, policies and internal procedures. * Perform quality assessments, verification and approval checking, releasing and audit confirmation of withdrawal, death and disability claims to ensure accurate and compliant processing. * Ensure all tasks are completed accurately, efficiently and within agreed deadlines, maintaining high standards of work quality. * Monitor and manage the inflow and outflow of work within the team to ensure effective workload management and timely processing. * Identify, flag and escalate outstanding or incomplete work to the reporting manager to prevent unnecessary delays and backlogs. * Investigate, analyse and monitor stops placed on claims, identifying underlying issues and ensuring appropriate follow-up and resolution. * Assist administrators with data amendments, rollbacks, delegations and ad hoc reporting requirements. * Ensure all internal and external queries are handled professionally, accurately and within agreed service level agreements. Process Improvement and Systems Management: * Identify opportunities to improve claims administration processes, operational efficiency, accuracy and customer satisfaction. * Review, develop, enhance and document policies, procedures and processes relevant to the Claims and Exits team, submitting recommendations to the reporting manager for consideration and approval. * Analyse operational data, identify recurring trends and recommend practical and innovative solutions to improve service delivery and prevent future issues. * Investigate and analyse escalated complaints, claims-related challenges and operational issues, identifying root causes and proposing corrective and preventative measures. * Report identified trends and obtained approval from the reporting manager before implementing proposed solutions or preventative measures. * Participate in user acceptance testing UAT of processes and system enhancements on Everest to ensure functionality, accuracy and operational effectiveness. * Implement, monitor and manage operational controls within the team, including the movement of switches, merges and other relevant transactions. * Support continuous improvement initiatives by identifying system and process inefficiencies and recommending workable solutions. Operational Management and Administration: * Compile and submit accurate, comprehensive and timely reports to the reporting manager in the required format and within agreed deadlines. * Provide regular updates on claims processing performance, work progress, outstanding matters, delays, backlogs and operational challenges to ensure management remains informed. * Analyse claims data and operational trends, highlighting areas of concern and recommending corrective actions or process improvements. * Ensure all daily, weekly and monthly statistical reports are prepared, verified and submitted timeously. * Maintain professional and effective communication with clients, stakeholders and internal teams, ensuring claims-related queries and concerns are addressed appropriately. * Ensure that all reports required by trustees, management and the business are prepared, managed and submitted accurately and within the required timelines. * Track and report on the progress and completion of action items arising from trustee meetings. * Assist with the preparation of audit-related reports and supporting documentation, ensuring accurate and timely responses to audit queries. Relationship Management: * Compile and submit accurate, comprehensive and timely reports to the reporting manager in the required format and within agreed deadlines. * Provide regular updates on claims processing performance, work progress, outstanding matters, delays, backlogs and operational challenges to ensure management remains informed. * Analyse claims data and operational trends, highlighting areas of concern and recommending corrective actions or process improvements. * Ensure all daily, weekly and monthly statistical reports are prepared, verified and submitted timeously. * Maintain professional and effective communication with clients, stakeholders and internal teams, ensuring claims-related queries and concerns are addressed appropriately. * Ensure that all reports required by trustees, management and the business are prepared, managed and submitted accurately and within the required timelines. * Track and report on the progress and completion of action items arising from trustee meetings. * Assist with the preparation of audit-related reports and supporting documentation, ensuring accurate and timely responses to audit queries. Reporting: * Compile and submit accurate, comprehensive and timely reports to the reporting manager in the required format and within agreed deadlines. * Provide regular updates on claims processing performance, work progress, outstanding matters, delays, backlogs and operational challenges to ensure management remains informed. * Analyse claims data and operational trends, highlighting areas of concern and recommending corrective actions or process improvements. * Ensure all daily, weekly and monthly statistical reports are prepared, verified and submitted timeously. * Maintain professional and effective communication with clients, stakeholders and internal teams, ensuring claims-related queries and concerns are addressed appropriately. * Ensure that all reports required by trustees, management and the business are prepared, managed and submitted accurately and within the required timelines. * Track and report on the progress and completion of action items arising from trustee meetings. Required Qualifications & Experience: * Matric Grade 12 * Proficiency in Microsoft Excel * Knowledge of FICA, POPIA & Treating Customers Fairly TCF principles * Strong written and verbal communication skills * Stakeholder management CRM * Industry knowledge and experience * Accuracy and attention to detail * Judgement and Decision Making * Working under pressure And Deadline driven * Interpersonal skills * Investigative and risk management skills * Cross team collaboration * Management of time * People Management * Analysis of data