GapCover Claims Assessor


The company is seeking another Claims Assessor to join the team. This role will form part of the Administration team, and report to the CEO.

Primarily an Administration function, the role will be responsible for the following

  • Effective coordination of the end-to-end policy claims process, i.e.
  • Claims administration
  • Claims assessment
  • Claims authorisation
  • Ownership of the policy claims process and associated SLAs
  • Collation and evaluation/assessment of claims documentation
  • Correspondence with clients regarding the progress and outcomes of claims assessment process
  • Liaison/Correspondence with 3rd parties regarding access to information required to assess claims
  • Liaison/Correspondence with authoritative and legal entities such as the Council for Medical Schemes, the Ombudsman, etc.
  • Thorough evaluation, assessment and authorisation of claims
  • Recording and communication of outcomes of claims
  • Management and coordination of claims payment runs
  • Assistance with other functions within Administration area if and when required


Generic key result areas

  • Claim Processing and operational effectiveness
  • Functions as a subject matter expert in a specific field of administration / product / process
  • Resolves technical and complex problems in support of administrative queries/issues
  • Personal effectiveness
  • Accountable for client service delivery through own efforts
  • Accountable for managing own time, tasks and output quality
  • Makes increased contributions by broadening individual skills
  • Accepts and lives the company values
  • Effective team player with high level of interpersonal skills
  • Quality Assurance
  • Performs quality checks on own work
  • Adheres to service and quality standards


Requirements for the role

  • Knowledge and experience of claims processing
  • Minimum 3 years’ experience in Medical Scheme/Health Insurance industry
  • Very strong client service focus
  • Attention to detail
  • Strong analytical skills
  • Relationship management skills
  • Strong administration skills
  • Operational efficiency


Desired Work Experience

  • 3 to 5 years


Desired Educational Level

  • Grade 12 / Matric

Our Vision

At Optivest, medical schemes and medical scheme related products are our speciality.
It is our vision to enable all South Africans to get medical cover, that suits their individual and family needs while saving them money.