Unit of Competency Mapping – Information for Teachers/Assessors – Information for Learners

FNSPIM304A Mapping and Delivery Guide
Manage claims

Version 1.0
Issue Date: May 2024


Qualification -
Unit of Competency FNSPIM304A - Manage claims
Description This unit describes the performance outcomes, skills and knowledge required to manage personal injury claims from receipt of claim to closure. It encompasses assessing and determining claim liability, identifying potential fraud indicators and facilitating interaction with stakeholders to determine the outcome of a claim.This unit may apply to job roles subject to licensing, legislative, regulatory or certification requirements so Commonwealth, State or Territory requirements should be confirmed with the relevant body.
Employability Skills This unit contains employability skills.
Learning Outcomes and Application This unit applies to job roles involving responsibility for processing and managing personal injury claims.
Duration and Setting X weeks, nominally xx hours, delivered in a classroom/online/blended learning setting.
Prerequisites/co-requisites
Competency Field
Development and validation strategy and guide for assessors and learners Student Learning Resources Handouts
Activities 		Slides
PPT 		Assessment 1 Assessment 2 Assessment 3 Assessment 4
Elements of Competency Performance Criteria              
Element: Assess claim and determine liability
  • Gather claiminformation in accordance with organisation guidelines and legislative requirements
  • Review validity of claim in accordance with organisation and legislative requirements
  • Return invalid claims or information to claimant for correction
  • Enter claims into organisation claims management system in accordance with organisation guidelines and codes of practice and time requirements
  • Refer claim to appropriate risk assessment area in accordance with organisation delegation authorities
       
Element: Identify potential risk indicators
  • Highlight and identify areas of risk within claim including fraudulent and inappropriate behaviour
  • Use information collected during the claims registration process to assess the risk of the claim
  • Follow organisation tools and procedures for the management of risk and identify potential risk areas that may lead to escalation
  • Follow organisation procedures for escalation
       
Element: Facilitate interaction and consult with stakeholders
  • Plan and implement strategies in accordance with stakeholders
  • Document referral process with stakeholders' involvement
  • Record stakeholder interaction in accordance with legislative and organisation standards
  • Record agreed actions and undertakings as outlined by stakeholders
  • Identify and document contingency and corrective action plans
  • Determine medical liability in consultation with stakeholders and related parties
  • Prepare case for conference in accordance with organisation guidelines
  • Undertake agreed actions as a result of conferencing
       


Evidence Required

List the assessment methods to be used and the context and resources required for assessment. Copy and paste the relevant sections from the evidence guide below and then re-write these in plain English.

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:

collect accurate information during the claims registration process, in particular the return to work (RTW), return to health status of the claim and the nature of the injury

assess claims and determine entitlements and identify any fraud indicators within claim applications

facilitate interaction with relevant stakeholders, demonstrating knowledge of organisation claims processing requirements

interpret and apply relevant legislative requirements regarding claim processing.

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

Submission Requirements

List each assessment task's title, type (eg project, observation/demonstration, essay, assignment, checklist) and due date here

Assessment task 1: [title]      Due date:

(add new lines for each of the assessment tasks)

Assessment Tasks

Copy and paste from the following data to produce each assessment task. Write these in plain English and spell out how, when and where the task is to be carried out, under what conditions, and what resources are needed. Include guidelines about how well the candidate has to perform a task for it to be judged satisfactory.

Required skills

communication skills to:

determine and confirm information, using questioning and active listening as required

establish and use a network of stakeholders for the management of personal injury claims

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

use internet information

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 and testing assumptions, taking into account the context of claim information gathered

effective interpersonal skills

organisation skills, including the ability to plan and sequence work

problem solving skills to apply strategies across a range of areas to determine validity and liability of personal injury claims

team working skills for working as part of as team to effectively manage a personal injury claim and to work with a range of stakeholders

Required knowledge

organisation claims management IT systems

organisation policies and procedures as they relate to the capture, processing and management of personal injury claims

relevant personal injury legislation

relevant stakeholder parties within the personal injury sectors to manage personal injury claims effectively

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.

Claim information may include:

claim form

consultation with the injured person

consultation with relevant parties

dates covered on medical certificates.

Organisation guidelines and codes of practice may include:

agency of injury

bodily location of injury

claim category (e.g. medical only or temporary disability)

mechanism of injury

nature of injury

occupation of injured person.

Fraudulent and inappropriate behaviour may be from:

the injured person

service providers.

Stakeholders may include:

case managers

community groups

employers

health management specialist

injury management adviser

investigation specialist

legal panel

social rehabilitation specialists

technical manger

vocational rehabilitation specialists.

Related parties may include:

the employer

the family of the injured person.

Copy and paste from the following performance criteria to create an observation checklist for each task. When you have finished writing your assessment tool every one of these must have been addressed, preferably several times in a variety of contexts. To ensure this occurs download the assessment matrix for the unit; enter each assessment task as a column header and place check marks against each performance criteria that task addresses.

Observation Checklist

Tasks to be observed according to workplace/college/TAFE policy and procedures, relevant legislation and Codes of Practice Yes No Comments/feedback
Gather claiminformation in accordance with organisation guidelines and legislative requirements 
Review validity of claim in accordance with organisation and legislative requirements 
Return invalid claims or information to claimant for correction 
Enter claims into organisation claims management system in accordance with organisation guidelines and codes of practice and time requirements 
Refer claim to appropriate risk assessment area in accordance with organisation delegation authorities 
Highlight and identify areas of risk within claim including fraudulent and inappropriate behaviour 
Use information collected during the claims registration process to assess the risk of the claim 
Follow organisation tools and procedures for the management of risk and identify potential risk areas that may lead to escalation 
Follow organisation procedures for escalation 
Plan and implement strategies in accordance with stakeholders 
Document referral process with stakeholders' involvement 
Record stakeholder interaction in accordance with legislative and organisation standards 
Record agreed actions and undertakings as outlined by stakeholders 
Identify and document contingency and corrective action plans 
Determine medical liability in consultation with stakeholders and related parties 
Prepare case for conference in accordance with organisation guidelines 
Undertake agreed actions as a result of conferencing 

Forms

Assessment Cover Sheet

FNSPIM304A - Manage claims
Assessment task 1: [title]

Student name:

Student ID:

I declare that the assessment tasks submitted for this unit are my own work.

Student signature:

Result: Competent Not yet competent

Feedback to student

 

 

 

 

 

 

 

 

Assessor name:

Signature:

Date:

Assessment Record Sheet

FNSPIM304A - Manage claims

Student name:

Student ID:

Assessment task 1: [title] Result: Competent Not yet competent

(add lines for each task)

Feedback to student:

 

 

 

 

 

 

 

 

Overall assessment result: Competent Not yet competent

Assessor name:

Signature:

Date:

Student signature:

Date: