Team Leader: Complaints and Escalations (Gap Cover)

Complaints and Escalations Team Leader

Job Purpose:

To lead the Complaints and Escalations Team in efficiently managing and resolving complex customer complaints and high-level escalations related to medical aid and gap cover claims and administration. The role ensures timely resolution, compliance with regulatory requirements, root cause analysis, and the implementation of service recovery and improvement strategies.

Key Responsibilities:

Team Leadership:

• Lead, coach, and develop a team of Complaints & Escalations Officers to ensure high performance.
• Allocate and prioritise workload to meet SLAs and turnaround times.
• Monitor and evaluate team performance through KPIs and feedback sessions.
• Foster a culture of accountability, empathy, and continuous improvement.

Complaint and Escalation Handling:

• Oversee the investigation, resolution, and closure of complaints from members, intermediaries, and regulatory bodies (e.g., CMS, FAIS Ombud).
• Handle complex or high-risk complaints directly, ensuring effective communication and resolution.
• Ensure all escalations are logged, tracked, and resolved within agreed timelines and in line with company procedures.

Compliance and Reporting:

• Ensure complaints handling complies with relevant legislation and industry standards (e.g., POPIA, FAIS, Treating Customers Fairly).
• Prepare monthly reports on trends, root cause analysis, resolution times, and team performance.
• Escalate systemic or recurring issues to management with recommendations for corrective action.

Stakeholder Engagement:

• Work closely with internal departments (Claims, Underwriting, Contact Centre, IT) to investigate and resolve issues.
• Liaise professionally with external stakeholders such as medical schemes, insurers, brokers, and members.
• Provide feedback and insights to internal stakeholders to support product and process improvements.

Continuous Improvement:

• Identify root causes of complaints and work cross-functionally to implement preventative measures.
• Drive initiatives aimed at improving service delivery and enhancing customer satisfaction.
• Maintain and update complaint handling SOPs and training materials.

Required Qualifications and Experience:

• Matric (Grade 12) – Essential.
• Relevant tertiary qualification (e.g., in Healthcare Administration, Customer Service, or Business Management) – Preferred.
• FAIS-compliant (RE5) – Advantageous.
• Minimum 3-5 years’ experience in a customer service or complaints role within a medical aid, health insurance, or gap cover environment – Essential.
• At least 1-2 years’ leadership or supervisory experience – Essential.
• Knowledge of claims processing and medical scheme legislation – Highly advantageous.

Skills and Competencies:

• Excellent written and verbal communication skills.
• Empathetic and assertive customer handling.
• Strong conflict resolution and problem-solving skills.
• Attention to detail and ability to manage sensitive or regulated information.
• Strong analytical and reporting skills.
• Ability to remain calm under pressure.
• Proficiency in CRM systems and Microsoft Office Suite.
• Organised and able to prioritise in a fast-paced environment.

Key Performance Indicators (KPIs):

• Complaint resolution turnaround time.
• Escalation response times.
• Quality of written responses.
• Compliance with regulatory and internal processes.
• Team performance and engagement.
• Reduction in repeat complaints / root cause closure.