Unit of competency details

Unit descriptor 

This unit describes the performance outcomes, skills and knowledge required to manage personal injury claims from receipt of claim to closure. It encompasses assessing and determining claim liability, identifying potential fraud indicators and facilitating interaction with stakeholders to determine the outcome of a claim.

This unit may apply to job roles subject to licensing, legislative, regulatory or certification requirements so Commonwealth, State or Territory requirements should be confirmed with the relevant body.

Application of the unit 

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

Prerequisite units 

Employability skills 

This unit contains employability skills.

Elements describe the essential outcomes of a unit of competency.

Performance criteria describe the performance needed to demonstrate achievement of the element. Where bold italicised text is used, further information is detailed in the required skills and knowledge section and the range statement. Assessment of performance is to be consistent with the evidence guide.

ELEMENT 

PERFORMANCE CRITERIA 

1. Assess claim and determine liability

1.1. Gather claim information  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 AND KNOWLEDGE 

This section describes the skills and knowledge required for this unit.

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

EVIDENCE GUIDE 

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 

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:

• 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

Competency field 

Co-requisite units