Care Coordinator

One Team Health, a subsidiary of Argus Group Holdings Limited, is currently seeking a Care Coordinator. This role will manage healthcare services for members from inception to completion of the claims process. Ensuring services are eligible, medically appropriate and in adherence with policy guidelines. Coordinating and communicating with our claimants, providers, and employers. Also assisting with processing and adjudication of medical claims to ensure correct and timely payment.

We are seeking an individual who is well organized, enthusiastic, and who can consistently meet and exceed the expectations of the day-to-day operations of the Health Services team.

**PRIMARY DUTIES AND RESPONSIBILITIES**:

- Evaluate and ensure eligibility and benefits based on the terms and conditions of the member’s medical insurance policy.
- Present cost-effective options for treatment by utilizing network facilities and collaborating with the Relationship Management team as applicable.
- Assess appropriate diagnostic testing and treatment plans as per published standards and as determined by the medical team.
- Maintain all records of activity related to the management of the case inclusive of financial expectations and treatment planning, financial expectations, and treatment strategy within the company database system.
- Provide excellent customer service to the insured members, offering guidance and support throughout the duration of their medical treatment.
- Maintain comprehensive and accurate case notes along with other relevant data required to effectively process claims.
- Adhere to all policies and procedures as outlined by the company and client specific protocols.
- Perform all work in a PIPEDA and HIPAA compliant manner.
- Ensure strict standards for claimant/client confidentiality and comply with organizational and governmental regulations/policies.
- Participate in a weekly rotating On-Call schedule to support after-hour escalations.
- Participation in statutory holiday coverage.
- Manage and assist in the process of adjudicating overseas medical claims within the terms of the policy.
- Work closely with Health Claims Specialist as required to maintain the Health Claims System.
- Communicate with clients and providers as required verbally and in writing.
- Analyze complex medical claims based on a thorough knowledge of policy provisions and company guidelines on contentious claims.
- Assist with the processing of overseas health claims.
- Undertake any other duties and responsibilities commensurate with this level of appointment.

**REQUIREMENTS**:

- Three to five years of experience in the insurance industry or in other related fields (e.g. Healthcare)
- Two or more years previous health claims experience
- University or College degree in a related field (e.g. Business Administration, Insurance, Healthcare etc.) or equivalent work experience
- Math Skills: Calculating applicable discounts according to direct contract providers.
- Working knowledge of Health Claims Systems as it relates to Claims Adjudication and reporting system
- Knowledge of medical terminology and medical procedures (familiarity with medical procedures through experience in a hospital or medical facility)
- Strong interpersonal skills and the ability to prioritize and manage time effectively.
- Ability to interact with various stakeholders to assist with group client maintenance and acquisition.
- Ability to interact diplomatically with internal and external customers.
- Organizational and stress management skills.
- Strong communication skills both verbal and written.
- Problem-Solving and decision-making skills.
- Research orientated.
- Observational.
- Client focused.
- Ability to work independently.

In Ontario, One Team Health, and affiliated organizations accommodate the needs of job applicants throughout its recruitment and selection processes in accordance with the Ontario Human Rights Code and the Accessibility for Ontarians with Disabilities Act. Accommodation needs must be provided in advance. To discuss your needs, please contact the individual noted in the posting.

**Job Types**: Full-time, Permanent

Additional pay:

- Bonus pay

**Benefits**:

- Extended health care
- RRSP match
- Work from home

Schedule:

- Monday to Friday

Application question(s):

- What are your salary expectations? Please provide a range

**Experience**:

- third party insurance: 2 years (preferred)
- health claims: 2 years (preferred)

Work Location: Hybrid remote in North York, ON M2J 4Y1

Application deadline: 2025-02-24