Senior Claims Assessor – Pet Insurance

Location: Granger Bay, Cape Town, Western Cape
Employment Type: Full-Time
Salary: Market-related

About the Client

Our client is a reputable organisation within the financial services industry, providing specialised insurance solutions and committed to delivering efficient, professional and high-quality service to its clients and stakeholders.

About the Role

Our client is seeking an experienced Senior Claims Assessor – Pet Insurance to join their Cape Town team.

The successful candidate will be responsible for overseeing claims assessment activities, ensuring claims are processed in accordance with defined service-level agreements and standard operating procedures, managing escalated and complex claims, monitoring workflow and supporting the development of the claims team.

This role requires a technically strong claims professional who is comfortable handling complex cases, complaints, payment approvals, pre-authorisations and technical claims investigations while maintaining a high level of accuracy, professionalism and customer service.

Key Responsibilities

Claims Team Oversight and SLA Compliance

• Ensure claims are processed in line with defined service-level agreements and standard operating procedures, maintaining a minimum of 98% compliance.

• Monitor daily claims processing and proactively identify and address potential backlogs or unattended claims.

• Provide real-time support to team members with escalated or complex claims queries.

• Register, investigate and respond to first-level complaints received from brokers, clients or internal stakeholders.

• Prepare weekly SLA compliance reports for internal tracking and management review.

• Compile monthly claims reports for submission to the Finance team.

Claims Queries and Payment Approvals

• Complete final daily approval of claims within the required authority limits.

• Manage and create daily claims payment BDX files for upload to banking platforms.

• Assist with the resolution of complex claims queries from internal and external stakeholders.

Technical Claims Investigations and Processing

• Investigate OSTI and non-disclosure cases, providing detailed analysis and recommendations.

• Participate in claims committee and escalation meetings and provide technical input where required.

• Handle escalated claims rejections and contribute to decisions relating to claim repudiations.

• Act as a specialist technical assessor for complex claims matters.

Authorisations

• Review and process pre-authorisation requests against policy benefits, veterinary histories and product information.

• Approve or decline quotations in accordance with standard operating procedures and product guidelines.

• Communicate pre-authorisation outcomes clearly to brokers and clients.

• Refer complex matters to the relevant committee or consulting veterinarians where required.

• Assist team members with difficult or exceptional pre-authorisation cases.

Claims Calculations and Processing

• Ensure claims are processed accurately and in accordance with policy benefits and internal procedures.

• Provide technical input on complex claim decisions.

• Support junior team members where additional technical guidance is required.

• Collaborate with the relevant committee on exceptional or grey-area claims.

Training and Upskilling

• Support the onboarding and training of new claims employees.

• Assist with the ongoing development of existing team members through coaching, knowledge-sharing and process updates.

• Prepare and deliver training material.

• Contribute to process documentation and improvements to standard operating procedures.

Minimum Requirements

• Grade 12 with Mathematics.

• RE5 qualification is required.

• NQF Level 4 qualification in Short-Term Insurance is advantageous.

• Three to five years' experience in pet insurance claims or a similar environment.

• Strong understanding of insurance products, policy interpretation and technical claims assessment.

• Knowledge of veterinary terminology.

• Proficiency in Microsoft Office, including Excel, Word and Outlook.

• Strong analytical and problem-solving abilities.

• Excellent written and verbal communication skills.

• Strong customer service orientation.

• Proven ability to manage competing priorities and deliver against service-level requirements.

• High level of accuracy and attention to detail.

• Strong empathy and professionalism.

Ideal Candidate

The ideal candidate will be a proactive, organised and solution-focused claims professional who is comfortable working within a high-volume environment and managing multiple priorities.

They will have strong technical claims knowledge, excellent mentoring and coaching abilities and the confidence to support colleagues with complex or escalated matters. The successful candidate will demonstrate integrity, accountability and professionalism, remain calm under pressure and have a strong focus on continuous improvement and delivering a high standard of service.

If you have strong pet insurance claims experience and are looking for your next opportunity within the financial services industry in Cape Town, we would love to hear from you.