Application
This unit applies to claims management job roles in the personal injury management sector. |
Elements and Performance Criteria
ELEMENT | PERFORMANCE CRITERIA |
1. Receive and clarify claim information | 1.1. Claim information is received and entered into relevant organisation systems 1.2. Claim is processed in accordance with required timeframes and according to relevant Acts, regulations and organisation procedures 1.3. Correspondence is completed in accordance with organisation policies and procedures, and is allocated to relevant claims personnel 1.4. Clients are advised of organisation claims procedures and queries are responded to in an appropriate manner 1.5. Claim information is checked for accuracy and validity in accordance with organisation policies and procedures |
2. Determine status of claim | 2.1. All information is analysed against regulatory requirements and organisation guidelines to determine liability 2.2. Claims are referred to specialists where required and in accordance with organisation guidelines |
3. Accept or reject claim | 3.1. Liability decision is made in accordance with organisation guidelines, regulatory requirements, industry codes of practice and defined timeframes 3.2. Referral procedures are observed where claim amounts are outside settlement and/or claims management authority 3.3. Decision on liability is determined considering review and feedback from external stakeholders |
4. Document liability decision | 4.1. Liability decisions are communicated to relevant stakeholders in accordance with regulatory requirements, operating procedures and relevant codes of practice 4.2. Reasons for decisions are communicated promptly to clients and other relevant stakeholders 4.3. Decisions are documented and filed to demonstrate the basis on which the claim decision was determined, including all evidence and information that was considered, where appropriate |
Required Skills
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Required skills |
communication skills to: determine and confirm information, using questioning and active listening as required 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) 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 interpret accountability requirements manage organisation and claims classifications understand organisation delegation and authority levels follow organisation policies and procedures understand policy coverage, interpretation and application research and analysis skills for accessing and interpreting relevant information into meaningful terms effective interpersonal skills organisation skills, including the ability to plan and sequence work |
Required knowledge |
analysis and research methods analysis and organising data into meaningful terms decision making processes insurance policies, reports and related documents organisation claims processing software organisation operating procedures to assist with determining claim liability relevant workers compensation, personal injury Acts and regulatory requirements |
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: receive and clarify information and determine the status of a claim using organisation guidelines and regulatory requirements document liability decision using organisation guidelines, demonstrating knowledge of relevant Acts and regulations and organisation policies and procedures analyse information to draw meaningful conclusions read and interpret insurance policies, reports and related documents. |
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. | |
Claim information may include identifying: | data policy previous history with the organisation risk. |
Organisation procedures may include: | initiation of new claims processing of routine claims. |
Specialists may include organisation specialists or outside service providers such as: | accountants allied health practitioners investigators legal providers loss assessors medical practitioners. |
Referral procedures may involve: | referral to the next level of authority. |
Decisions may involve: | consultation fact finding research. |
Filing may include: | electronic paper documents. |
Sectors
Unit sector | Personal injury management |
Employability Skills
This unit contains employability skills. |
Licensing Information
Not applicable.