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Adil Edwards

Adil Edwards

Claims Assessor
South Africa, West Coast District Municipality

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About Adil Edwards:

am a self-motivated individual; I can
work well under pressure. A highly
ambitious individual who is goal driven
and a team-player with the ability to
work well on my own and always
ensuring all targets and goals are met.
I have excellent communication skills
with the ability to liaise at all levels.
For all the above reasons and more, I
believe that I will not only be suitable
for the position but will add value to
your company.

Experience

GAP Cover Claims Assessor - Ensure all documents are received in line with the claim form completed as stipulated.
Capture claim on system as stipulated on accounts.
Ensure all information captured are accurate such as dates, patient details, as well as medical and practice details.
Request outstanding information from clients (telephonic & e-mail) and communicate with brokers/clients/doctor’s rooms
to ensure the outstanding requirements are received.
Assess claims according to the rules, benefits, and conditions of the policy and within the SLA.
Contact service providers for discounts when claims are over the company prescribed threshold, identify and facilitate
claims in excess of R10,000.00 and request by liaising with doctor’s rooms in order to provide discount, change payment
methods to provider in order to receive the amount directly from the insurer.
Ensure that all policy limitations, waiting periods, and exclusions are appropriate and in line with the policy.
Attending to disputes and escalations from Compliance as and when required by the business.
Accurate and detailed reporting of all stats and claims processed.
Identify system issues as discrepancies arise.
Quality assurance self-check.
Any other duties as assigned by your manager from time to time.

Executive Relationship Manager - Conserving the business by resolving final escalations through to resolution.
Handling and administering policies and various financial changes thereof including the reprocessing of claims that were
initially processed incorrectly.
Maintain and foster longstanding client relationships.
Liaising with various stakeholders such as brokers, franchises as well as other internal departments to ensure our clients
receive superior service in the industry and are always treated fairly.
Analysing market and business trends to provide efficient performance standards externally and internally.
Drafting and signing-off of Standard Operating Procedures (SOPs).
Liaising with various internal stakeholders to improve overall functionality and actively researching and optimizing
operational activity within the business.
Involved in various key decision-making regarding Pilot/first-time projects – Headed the GAP cover initiative.

Education

Octomate Education
March 2021 – February 2022
Completed the FETC Short Term Insurance NQF L4 Qualification with 150
FAIS Credits, SAQA ID (49929) with Octomate, verified by the INSETA.
 

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