This unit applies to job roles involving responsibility for processing and managing personal injury claims.

ELEMENT

PERFORMANCE CRITERIA

1. Assess claim and determine liability

1.1. Gather claiminformation in accordance with organisation guidelines and legislative requirements

1.2. Review validity of claim in accordance with organisation and legislative requirements

1.3. Return invalid claims or information to claimant for correction

1.4. Enter claims into organisation claims management system in accordance with organisation guidelines and codes of practice and time requirements

1.5. Refer claim to appropriate risk assessment area in accordance with organisation delegation authorities

2. Identify potential risk indicators

2.1. Highlight and identify areas of risk within claim including fraudulent and inappropriate behaviour

2.2. Use information collected during the claims registration process to assess the risk of the claim

2.3. Follow organisation tools and procedures for the management of risk and identify potential risk areas that may lead to escalation

2.4. Follow organisation procedures for escalation

3. Facilitate interaction and consult with stakeholders

3.1. Plan and implement strategies in accordance with stakeholders

3.2. Document referral process with stakeholders' involvement

3.3. Record stakeholder interaction in accordance with legislative and organisation standards

3.4. Record agreed actions and undertakings as outlined by stakeholders

3.5. Identify and document contingency and corrective action plans

3.6. Determine medical liability in consultation with stakeholders and related parties

3.7. Prepare case for conference in accordance with organisation guidelines

3.8. Undertake agreed actions as a result of conferencing

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 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

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.

Unit sector

Personal injury management

This unit contains employability skills.