Bulelwa Nqumba
King Williams Town
Summary
Senior Claims Assessor with extensive experience in evaluating complex hospital and life claims exceeding R300,000. Expertise in fraud risk assessment and stakeholder engagement, ensuring timely claim finalization within service level agreements. Proven ability to meet targets and communicate effectively with clients, both in writing and verbally. Focused on enhancing claims management skills while upholding high standards of client service.
Overview
13
13
years of professional experience
Work History
Senior Claims Assessor
Assupol Life
07.2018 - 01.2024
- Assess Hospital Documents and make decision on the claim.
- Assess Life claims worth more than R300 000 with claims specialist and reinsurers.
- Assessing telesure claims
- Identifying trends and arrears of concern and escalate accordingly
- Assessing and processing group claims.
- Fraud risk assessment by identifying potential
- Confirming admissions with hospitals
- Give decisions on admission claims and create relevant claim forms.
- Responding in writing of the decision on claim.
- Pay or repudiate a claim based on the clinical evidence submitted.
- Investigate pre-existing conditions.
- Investigation contributing factors for the admission.
- Stakeholder engagement about the outcome
- Finalising a claim within SLA
- Stakeholder engagement
- Informing the client about the outcome of the claim telephonically.
Hospital Claims Assessor
Clientele
11.2016 - 06.2018
- Assess Hospital Documents and make decision on the claim.
- Responding in writing of the decision on claim.
- Pay or repudiate a claim based on the clinical evidence submitted.
- Investigate pre-existing conditions.
- Investigation contributing factors for the admission.
- Finalising a claim within SLA
- Informing the client about the outcome of the claim telephonically.
Claims Outbound Agent
Sanlam Sky
11.2012 - 10.2016
- 4 years claim assessment experience.
- Target of 60 claims and calls daily on following work flows:
- Death claims
- Hospital claims
- Refunds claims
- Retirement Annuity
- 2 years Outbound team and Assessment of claims
- Target of 70 calls daily
- Informing clients of the outstanding requirements on the following work flows:
- Death claims
- Hospital claims
- Refunds claims
- Retirement Annuity
- Assisting clients with other general queries.
- Processing policy changes.
- Updating client’s details.
- Responding to correspondence received internally and externally.
- Filling of outstanding documents on the system.
Retentions Consultant (Premium Admin)
SanlamSky
01.2011 - 04.2012
- 1 Year 4 months experience in making outbound calls to clients
- Retaining Policies from lapsing
- Making arrangements for double debits.
- Informing clients on how to retain the policies
- Reaching a daily target of 40 policies a day.
- Doing month end report for my manager
- Responding to correspondence received internally and externally
- Investigate and solve queries regarding premiums
Education
Long term Insurance -
Inseta
Johannesburg, GP01.2011
Pastel Account -
Walter Sisulu University
01.2008
Matric -
Masixole High School
01.2005
Skills
- investigate fraudulent claims
- Liaise with clients via calls and in writing
- Hospitality
- Adhere to service level agreement
- Able to meet targets on time
Custom Section
Bulelwa Nqumba, Married, South African, Black, 8710061218083, Xhosa, Zulu, English, Own car with code 10 drivers license, +27 (0)732634641, Bulelwamhloli@gmail.com, Block1, Tshabo, King Williams Town, Eastern Cape, 5600, Matric, 2005, Masixole High School, Pastel Account, 2008, Walter Sisulu University, Part time photographer, 2009-2010, Klipfontein View, Johannesburg, Long term Insurance, 2011, Inseta, 2018-07-01, 2024-01-31, Senior Claims Assessor, Assupol Life, Assess Hospital Documents and make decision on the claim., Assess Life claims worth more than R300 000 with claims specialist and reinsurers., Assessing telesure claims., Identifying trends and arrears of concern and escalate accordingly., Assessing and processing group claims., Fraud risk assessment by identifying potential., Confirming admissions with hospitals., Give decisions on admission claims and create relevant claim forms., Responding in writing of the decision on claim., Pay or repudiate a claim based on the clinical evidence submitted., Investigate pre-existing conditions., Investigation contributing factors for the admission., Stakeholder engagement about the outcome., Finalising a claim within SLA., Stakeholder engagement., Informing the client about the outcome of the claim telephonically., 2016-11-01, 2018-06-30, Hospital Claims Assessor, Clientele, Assess Hospital Documents and make decision on the claim., Responding in writing of the decision on claim., Pay or repudiate a claim based on the clinical evidence submitted., Investigate pre-existing conditions., Investigation contributing factors for the admission., Finalising a claim within SLA., Informing the client about the outcome of the claim telephonically., 2012-11-01, 2016-10-31, Claims Outbound Agent, Sanlam Sky, 4 years claim assessment experience., Target of 60 claims and calls daily on following work flows: Death claims, Hospital claims, Refunds claims, Retirement Annuity., 2 years Outbound team and Assessment of claims., Target of 70 calls daily., Informing clients of the outstanding requirements on the following work flows: Death claims, Hospital claims, Refunds claims, Retirement Annuity., Assisting clients with other general queries., Processing policy changes., Updating client’s details., Responding to correspondence received internally and externally., Filling of outstanding documents on the system., 2011-01-01, 2012-04-30, Retentions Consultant (Premium Admin), SanlamSky, 1 Year 4 months experience in making outbound calls to clients., Retaining Policies from lapsing., Making arrangements for double debits., Informing clients on how to retain the policies., Reaching a daily target of 40 policies a day., Doing month end report for my manager., Responding to correspondence received internally and externally., Investigate and solve queries regarding premiums., SanlamSky, Kwena Manaka, Claims department team leader, 0113597911, kwenaman@sanlamsky.co.za, Clientele, Pamela Zondi, Manager (Claims Department), 0113203113, pzondi@clientele.co.za, Sanlam Sky, Bronwin Jacobs, Team Leader (Premium Admin), 0113597145, bronwinj@sanlamsky.co.za
Languages
English
Advanced
C1
xhosa
Advanced
C1
Sotho
Intermediate
B1
Drivers license
- Code 10 (2014)
Timeline
Senior Claims Assessor
Assupol Life
07.2018 - 01.2024
Hospital Claims Assessor
Clientele
11.2016 - 06.2018
Claims Outbound Agent
Sanlam Sky
11.2012 - 10.2016
Retentions Consultant (Premium Admin)
SanlamSky
01.2011 - 04.2012
Long term Insurance -
Inseta
Pastel Account -
Walter Sisulu University
Matric -
Masixole High School