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Requisition Title: Claims Adjudicator

Location: Fully Remote

Typical Day in 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.

• Outline all daily duties, responsibilities, tasks, and accountabilities
• 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..
• Commitment to Financial Efficiency and Continuous Improvement targets, as required
• Commitment to improving NPS (customer) scores based on overall goals
• Supporting the Business:
• 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)

Candidate Requirements/Must Have Skills:

• Exceptional Communication Skills: Proficient in both verbal and written communication for diverse internal and external audiences.
• Proficiency in Microsoft Office 365: Strong working knowledge of the Office 365 suite of programs.
• Detail-oriented with Quick Assessment Skills: This role requires a keen eye for detail, as it involves reviewing receipts, extracting data, and accurately inputting information into the system. An analytical mindset is essential to understand and make decisions based on the information presented.
• Team and Individual Effectiveness: Proven ability to work effectively both independently and as part of a team in a fast-paced environment.

Soft Skills

• Strong customer service focus
• Ability to take initiative
• Excellent interpersonal skills and the ability to interact and work with others at all levels to achieve customer resolution

Nice-To-Have Skills:

• Bilingual English/French is an asset
• Previous claims adjudication and/or relevant insurance or healthcare industry experience a definite asset
• Previous call center and/or data processing experience an asset

Education:

• Post-secondary education preferred or equivalent experience