Bilingual Claims Specialist

60 Yonge Street Toronto Ontario,M5E 1H5

Administers the initiation and set up of claims for Life, Accidental death & dismemberment, well woman, individual disability insurance, critical illness and group insurance products. Provides effective & efficient service and delivers the desired experience to policyholders, brokers, agents, claimants by answering incoming calls and managing general questions for a varied range of insurance products. Provides administration support in setting up new incoming claims, ensuring that all required information is received or requested. Answers questions (premium payments, eligibility) from policyholders, brokers, third party administrators and claimants related to the Group Insurance Products (LTD, STD, Life Insurance, CI & AD&D). Assesses claims based on their individual merit and adjudicates in a fair manner up to designated limit. Produces reports including time service, Group experience reports and monthly reports for all product lines.
- Identifies emerging issues and trends to inform decision-making.
- Develops solutions and makes recommendations based on an understanding of the business strategy and stakeholder needs.
- Provides advice and guidance to assigned business/group on implementation of solutions.
- Conducts independent analysis and assessment to resolve strategic issues.
- Supports the execution of strategic initiatives in collaboration with internal and external stakeholders.
- Builds effective relationships with internal/external stakeholders.
- Ensures alignment between stakeholders.
- Prepares report on claims trends and issues, and identifies issues or concerns that require remediation.
- Breaks down strategic problems, and analyses data and information to provide insights and recommendations.
- Monitors and tracks performance, and addresses any issues.
- Builds change management plans of varying scope and type; leads or participates in a variety of change management activities including readiness assessments, planning, stakeholder management, execution, evaluation and sustainment of initiatives.
- Leads or participates in defining the communication plan designed to positively influence or change behaviour; develops tailored messaging; and identifies appropriate distribution channels.
- Adjudicates the most complex claims such as higher profile claims, higher dollar value claims or claims with increased litigation risk.
- Applies medical knowledge to adjudicate claims and uses appropriate case management principles and tools for effective claims management.
- Executes the monthly quality assurance program for claims operations.
- Prepares quality assurance documentation, rating the effectiveness of the claims specialist and provides documented feedback.
- Identifies system enhancements for claims management systems to resolve identified negative claims trends or situations and improve overall effectiveness.
- Participates in testing of claims management systems to identify potential adverse impacts of any system change and escalates as required to mitigate the potential impacts.
- Leads/participates in the design, implementation and management of core business/group processes.
- Identifies business needs, designs/develops tools and training programs; may include delivery of training to audiences.
- Answers incoming calls by policyholders, brokers, agents, beneficiaries and claimants in an efficient and effective manner delivering the desired client experience by assisting with general questions and initiating claims forms for all products.
- Answers administrative questions from Group policyholders, insured’s, brokers, third part administrators and claimants.
- Adjudicate assigned claims for multiple products, including investigating claim details to determine validity, conducting telephone interviews, consulting with medical consultants and legal resources, coordinating independent assessments, analyzing financial information, documenting detailed case management action plans, making eligibility decisions, re-evaluating claims being appealed, initiating detailed and complex rehabilitation plans, communicating decisions verbally and in writing as required, and signing to release payments.
- Manages assigned case load in an effective manner, escalating any issues or concerns, to ensure ongoing effective claim operations.
- Addresses any claimant or policyholder issue as part of the conversation, escalating as required for any complaint situation.
- Follows established policies & procedures including authority and signing authority to manage the risks inherent in claims operations and escalate any issues or concerns.
- Participates in quality reviews addressing any issues identified to help reduce risk inherent in claims operations.
- Follows appropriate guidelines in addressing client concerns and complaints, including documentation of claims to the Complaint’s Ombudsman.
- Focus is primarily on business/group within BMO; may have broader, enterpr