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Elements and Performance Criteria

  1. Receive notification of claim
  2. Receive claim
  3. Record/register claim
  4. Estimate a claims reserve, including reinsurance as appropriate
  5. Create claim files or add information to existing files

Required Skills

Required skills

communication skills to

determine and confirm information using questioning and active listening as required

relate to customers

liaise with others share information listen and understand

use language and concepts appropriate to cultural differences

numeracy and IT skills to

perform calculations related to achieving required outcomes

use computer applications word processing spreadsheet database specific purpose computer systems to assist in achieving required outcomes

access and update records electronically

access webbased information services

literacy skills to read and interpret documentation from a variety of sources and record and consolidate relevant related information

research and analysis skills for accessing and interpreting relevant information

organisational skills including the ability to plan and sequence work

Required knowledge

IT and communications systems

organisation and industry sector policy wording

principles and methods of filing

product knowledge including any conditions and terms of reinsurance

relevant legislation and regulations organisation policy and procedures underwriting guidelines and authorities

Evidence Required

The Evidence Guide provides advice on assessment and must be read in conjunction with the performance criteria required skills and knowledge range statement and the Assessment Guidelines for the Training Package

Overview of assessment

Critical aspects for assessment and evidence required to demonstrate competency in this unit

Evidence of the ability to

fully comply with organisation operating procedures legislative requirements and industry codes of practice

use accuracy and attention to detail and thorough checking of data

Context of and specific resources for assessment

Assessment must ensure

competency is demonstrated in the context of the work environment and conditions specified in the range statement either in a relevant workplace or a closely simulated work environment

access to and the use of a range of common office equipment technology software and consumables

access to organisation records

access to organisation policies and procedures

Method of assessment

A range of assessment methods should be used to assess practical skills and knowledge The following examples in combination are appropriate for this unit

evaluating an integrated activity which combines the elements of competency for the unit or a cluster of related units of competency

observing processes and procedures in workplaces

verbal or written questioning on underpinning knowledge and skills

evaluating samples of work

accessing and validating third party reports

Guidance information for assessment

Range Statement

The range statement relates to the unit of competency as a whole. It allows for different work environments and situations that may affect performance. Bold italicised wording, if used in the performance criteria, is detailed below. Essential operating conditions that may be present with training and assessment (depending on the work situation, needs of the candidate, accessibility of the item, and local industry and regional contexts) may also be included.

Claims checking involves:

manual checklists or through data entry validation on computer systems and may include:

previous payment to claimant

claim has been sent to the wrong insurer

liability has not been accepted.

Entering claims data may include:

coding according to organisation requirements (entering statistical data).

Registering claims may involve:

entering claims reserve/estimate

identifying interested parties

identifying reinsurance involvement

linking to relative policy

observing limits to authority level

recording in system.

Organisation procedures may include:

correspondence presentation

initiation of new claims and processing of claims

security procedures.

Authorities may include:

a written policy and procedures manuals that define the level of authority to make decisions on claims within the organisation

guidelines/procedures relating to injury management and use of service providers.

Systems may be:

computerised, with record updating by electronic or manual data recording.

Service providers may include

accountants

assessors

auditors

engineers

investigators

medical advisers

private investigators

surveyors

others as required.

If reinsurance is identified:

check specific treaty and/or facultative coverage for catastrophic claims and allocate internal category code.

Reinsurance advice may include:

notifying the reinsurer of potential claim (if appropriate) by raising a credit/debit note.

Legislative and organisational requirements may include:

Health and Other Services (Compensation) Act

industrial relations legislation

Privacy Act

social security legislation

State and Territory workers compensation Acts and regulations

taxation legislation.