This unit applies to claims management job roles in the personal injury management sector.

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

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

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

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.

Unit sector

Personal injury management

This unit contains employability skills.