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Claims Examiner

3 months ago

Markham Ontario IP, CA VUMI Canada Inc. Full time

EPIC is searching for TOP TALENT

Epic brings a strong legacy of experience and in-depth knowledge gained from 35+ years in a challenging and ever-evolving marketplace. Part of an award-winning enterprise group, the affiliated healthcare companies have more than 450 employees worldwide. Senior leadership saw key synergies between National Healthcare Solutions, Inc. (NHSI) founded in 1992 and Ardent Assistance founded in 2017. Joining these two companies into a new entity, supplemented by VUMI’s exclusive Latin American proprietary network – enables Epic to offer solutions in all the Americas not available elsewhere in the marketplace.

We are seeking a Claims Examiner to become a part of our organization You will adjudicate claims based on the terms and conditions of the policy and will be responsible for issuing either payment or denial up to an authorized limit.

Duties & Responsibilities
  1. Investigates claims to determine eligibility based on policy provisions. Requests additional information/documentation where required.
  2. Establishes and maintains accurate reserves on claim files.
  3. Investigates possible subrogation and other insurance coverage available to the Insured to minimize losses.
  4. Subrogates and coordinates benefits where applicable.
  5. Verifies payments to validate reasonable and customary expenses.
  6. Maintains documentation and notes on each claim. Records all information, conversations and decisions relating to each claim on the system.
  7. Assists and answers all claims inquiries.
  8. Reviews claim documentation to establish eligibility for payment or denial claim.
  9. Notifies policyholders of claims decision, including details of the payment or sending denial letters. Reviews and presents all appeals received to the Appeals Committee for review.
  10. Utilizes recovery and cost containment strategies.
  11. Interprets policy wording and explains claims procedures to insurance brokers, travel agents and individual claimants.
Skills & Qualifications
  1. Strong investigative skills
  2. Negotiation skills
  3. Good communication skills
  4. Effective presentation skills
  5. Relationship Management skills
  6. Able to use MS office applications, Word, Excel and Access
  7. Have broad experience of working in a Claims environment
  8. Two – three years of experience in adjudicating medical claims
  9. Knowledge of medical terms and conditions an asset
  10. Demonstrated ability to communicate effectively with all stakeholders
  11. Demonstrated time management and organizational skills
  12. Bilingual (English/Spanish) would be considered an asset
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