This unit applies to job roles involving specialist knowledge and functions in a range of insurance sectors and may be applied within organisations of various sizes and across a range of customer bases. It may be applied to areas of claims assessment involving personal injury, long-term settlement and/or complex claims.

ELEMENT

PERFORMANCE CRITERIA

1. Establish the need to appoint a specialist to undertake the assessment

1.1. Facts, evidence and information, including fraud indicators, relevant to the circumstances of loss/damage/injury, are reviewed thoroughly, systematically and accurately

1.2. The need to appoint specialist assistance to undertake a financial, medical, or psychological assessment is identified and determined promptly and accurately and conveyed to the client and other relevant parties

2. Organise financial, medical or psychological assessments

2.1. Appointed specialists are engaged as required and thoroughly briefed

2.2. Assessment activity progress is monitored and reported to relevant parties, as appropriate, and adherence to timelines ensured

3. Analyse data for claims assessments

3.1. Financial, medical or psychological assessment data is analysed and assessed for thoroughness and consistency

3.2. Analysis tools to assess financial, medical and/or psychological assessments are used to calculate loss damages

3.3. Validity of loss situation and/or claims is assessed fairly and impartially against the assessment data and analysed against reported circumstances, available evidence, facts and information

3.4. Insurance cover/policy conditions are reviewed to ensure loss falls within policy coverage

4. Report results

4.1. Assessment actions, procedures and outcomes are documented and recorded promptly and accurately

4.2. Reporting includes recommendations on the validity of the claim and recovery amounts in relation to the assessment and other relevant data

4.3. Stakeholders are provided with accurate and timely advice regarding the financial, medical or psychological assessment for claim proceedings

Required skills

highly developed communication skills to:

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

relate effectively to customers

liaise with others, share information, listen and understand

use language and concepts appropriate to cultural differences

well-developed 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 web-based information services

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

learning skills to maintain knowledge of changes to compliance legislation and requirements

problem solving skills to identify any issues that have the potential to impact on work outcomes and to develop options to resolve these issues when they arise

self-management skills for complying with ethical, legal and procedural requirements research and analysis skills for accessing and interpreting relevant information

organisational skills, including the ability to plan and sequence work

Required knowledge

analysis practices and guidelines

claims management

data analysis techniques/procedures

policy coverage/requirements

principles of cost estimating

relevant legislation and industry codes of practice

roles/responsibilities of financial, medical and psychological specialists

types/categories of insurance policies

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:

interpret and adapt to circumstances in which specialist assistance should be sought in resolution of a claim

analyse claims information to determine the need for specialist assistance and application of skills to monitor the specialist assistance and interpret and report on the outcomes of the specialist advice in relation to the claim context.

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

setting and reviewing workplace projects and business simulations or scenarios.

Guidance information for assessment

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.

Specialist assistance may include:

accountants

chemists

consultants

legal

medical personnel

psychologist/psychiatrist

valuers.

Assessment activities may include:

consultation

credit and character checks

desktop and other research

financial checks

interviews

medical/physical examinations

psychological testing

surveys

valuations.

Documentation may include:

reasons for adopting/incorporating certain data/information preferred over other data/information

records of assessment documents/findings/reports

records of telephone conversations

reference to all assessment data/information considered

specialist/other correspondence related to the assessment process

the basis on which recommendations on the assessment outcome in relation to the claim were determined.

Stakeholders may include:

claimants

claims managers/specialists

insurance broker

underwriters

other relevant parties.

Unit sector

Insurance services

This unit contains employability skills.