Claims Service Associate

**Claims Service Associate**

**Company Overview**

Ellement Consulting Group (Ellement) is a privately-owned actuarial consulting firm established in 1996. We provide actuarial, administration, software programming, and consulting solutions for pension, benefits, and investment programs for individuals, corporations, unions, associations, and governments across Canada.

At Ellement, we empower our clients with informed choices and expert advice. Our mission centers on delivering purposeful, accessible experiences that prioritize customer obsession and operational excellence. We are committed to integrity, strategic foresight, and fostering symbiotic partnerships where challenges are met with collective brilliance and innovative solutions.

Our approach is straightforward and client-centric, ensuring that every interaction is clear, helpful, and devoid of unnecessary jargon. Confident and authentic, we strive to be more than consultants—we are reliable partners in our clients' success.

**Position Summary**

**Key Responsibilities**
- Analyze and process paperless and traditional claims for health, drug and dental using the claims system, ensuring accuracy and adherence to contract terms and maintaining high productivity and quality standards.
- Verify and validate submitted documents, ensuring provider credentials and enforcing necessary controls.
- Communicate with members and providers to obtain missing information
- Determines eligibility of members for benefits based on established criteria and approves or declines payment
- Reviews the claims on hold list to ensure any outstanding claims can be closed for payment. Will follow up with Group Admin to find out status of claims on hold pending provider updates or investigate code issues within 5 business days of submission
- Clarifies claims-related information with insurance carriers, Call Centre Agents, and Dental Consultant as required
- Completes Dental Consultant Referral Forms as required for major dental or orthodontic claims (i.e. pre-authorization for bridge work)
- Investigates and adjudicates private duty nursing claims, accidental dental claims, and Out of Country claims
- Thoroughly and accurately compiles and summarizes details with respect to claims adjustments or appeals
- Investigate inquiries that cannot be responded to immediately (i.e., potential coverage of new or non-routine procedures and therapies under specific benefit plans) by researching information to determine appropriate responses.
- Identify problems or errors and recommend or implements solutions.
- Contact members regarding stale dated cheques.
- Complete claim inquiries as directed within set service standards.
- Any other duties needed to help drive to our Vision, fulfill our Mission, and abide by our Organization’s Values

**Qualifications and Attributes**
- Post-secondary diploma in a related field, such as business administration or equivalent training acquired from a combination of relevant work experience and education.
- 1-5 years experience adjudicating medical/dental/vision claims
- Experience with the TELUS claims adjudication system would be an asset
- Analytical skills to research, review and assess claims
- Must have demonstrated ability to stay organized and multi-task
- Working knowledge of group benefits, insurance policies and claim processes.
- Attention to detail and commitment to accuracy of work.
- Proven customer service experience
- Excellent communication, negotiation, and interpersonal skills
- Ability to work independently and with a team
- Strong organizational and time-management skills
- Computer literacy and proficiency with Microsoft Office suite
- Excellent interpersonal, verbal and written communication skills
- Bilingual (English and French) is a benefit but not a requirement
- Ability to maintain professional conduct and tact while working in a dynamic inbound and outbound call centre environment
- **Successful completion of a cleared criminal background check is required.**

**Benefits**

At Ellement, we’re all about investing in our business, and our biggest investment is our people

We’re committed to our employees growth and well-being, offering ongoing education, training, and all the support you need to thrive. We offer a comprehensive benefits package, along with a positive, team-oriented work environment.

Join our vibrant and dynamic team today