Claims Adjudicator

4 weeks ago


Canada, CA Compunnel Inc. Full time

Job Summary( Primary purpose of this Role):

The Claims Adjudicator is accountable for handling claims in accordance with high service standards

to meet or surpass client expectations. The Adjudicator is required to make a number of determinations that may affect the member's entitlement to benefits and/or the amount of benefits that are payable. The Adjudicator reviews claims for completeness, enters and assesses claims, and produces the final statement and/or payment responsibility, after the member's insurance benefits are applied to a claim. The Adjudicator will be required to contact various practitioners or service providers to obtain clarification on claim information as necessary.


Individual Accountabilities:

Claims Adjudication 80%

  • Assesses highly complex health/dental claims in keeping with contract provisions, taking initiative and ensuring that empowered decision making is a key component of the process.
  • Assume ownership of the claims assigned with an understanding of the urgency of specific cases and effectively prioritize work accordingly.
  • Establish and maintain quality customer service within our turnaround times using influence with internal and external clients to meet all pre-established service standards in order to delight our customers..


Supporting the Business 20 %

  • Sound knowledge and ability to apply appropriate risk management tools and techniques.
  • Actively participate in various projects that improve effectiveness and efficiency in claims practices in keeping with our culture of continuous improvement.
  • Manage all issues and requirements related to the claim to achieve customer/claim resolution handing off only as appropriate.(claims adjustments, warranty investigation, technical decisions)


Key Shared Accountabilities:

  • Commitment to Financial Efficiency and Continuous Improvement targets, as required
  • Commitment to improving NPS (customer) scores based on overall CX goals
  • Commitment to the achievement of the divisional and organizational “Must Win Battles”


Job Requirements :

  • Post-secondary education or equivalent experience

Strong customer service focus and the ability to take the initiative

  • Previous claims adjudication and/or relevant insurance or health care industry experience a definite asset
  • Strong working knowledge of Microsoft Office 365 suite of programs
  • Detail oriented with quick assessment skills
  • Excellent interpersonal skills and the ability to interact and work with others at all levels to achieve customer resolution
  • Superior communication skills (verbal and written) for a variety of internal and external audiences (Both in English and French as applicable)

The ability to work effectively as an individual and as part of a team in a fast-paced environment


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