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Bilingual Claims Adjudicator I

2 months ago

Canada Compunnel Inc. Full time

Job Summary:


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.


Key Accountabilities:


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

Competencies:

  • Highly organized and flexible; possessing a resilient mindset and the ability to manage multiple tasks and deadlines while balancing conflicting priorities.
  • Ability to respond constructively and decisively in challenging situations and to respond positively to change.
  • Excellent problem-solving and efficient decision making skills
  • An analytical thinker who is detail, solution and action oriented; an active participant in various projects that improve effectiveness and efficiency in claims practices in keeping with our culture of continuous improvement.
  • Sound knowledge of medical/ dental terminology and practices as well as provincial legislation and regulations
  • Good understanding of the various business units in the Canadian Division, and globally


Decision Authorities:

• Decisions and actions directly impact the customers’ experience and how we operate

• Responsible for releasing payments of up to $7,000 per claim

• Clients have an expectation that we will manage claims correctly and on time. If this expectation is not met, we risk Client dissatisfaction and possible escalations exposing us to reputational risk.


Key Performance Goals/Measurement


Financial Targets:

As part of the broader CX and Canadian Division organization, positively contributing to achieving overall financial targets in order to meet customer, plan sponsor and shareholder expectations.


Key Metrics:

  • Ownership of personal results(Customer): ensuring a culture of excellence in customer service
  • Ownership of personal results(Quality):

Quality of claims processed

Quality of interactions with all stakeholders in the adjudication process

  • Ownership of personal results(Productivity): Meeting or exceeding time utilization targets to service as many customers as possible each day
  • Ownership of personal engagement: commitment to survey completion, provision of candid feedback
  • Ownership of continuous/process Improvements: supporting all initiatives designed to reduce customer and work effort
  • Positively contribute to net promoter scores by reducing effort and delivering excellent results for our customers


Organizational Assumptions:

  • The Claims Adjudicator is responsible for managing all routine and complex types as they present in the claims payment system according to an individuals’ set up based on skill set.
  • All work efforts must be conducted with a view to delighting external customers and creating a differentiated experience and the quality and timeliness of the adjudication has an impact.
  • This role is global in nature and involves collaborating across geographies and time zones with a variety of teams and functions to be successful
  • The skills utilized in this position directly affect the quality and the timeliness of service, thus having an impact on the Company’s reputation.
  • This position has a direct impact on the Company’s profitability and pricing of products.
  • Claims experience is directly affected by the quality of claims adjudication: assessment of claims according to the terms of the policy, detecting fraudulent claims, identifying unusual patterns and deviances, investigating claims completely and thoroughly, making appropriate claims decisions and settlements based on the terms of the contract and the circumstances surrounding the claim are all essential components.
  • Claim decisions may be challenged through the legal process which could jeopardize the Company’s reputation and open it up for damages
  • Claims adjudication by its very nature requires respect for confidentiality on the part of the Adjudicator a breach of which could jeopardize the Company’s reputation and increase risk profile



Critical Behaviours:


We Work as One

  • Influence and Persuasion
  • Compelling Communication
  • Collaboration


We Question and Innovate

  • Adaptability
  • Knowing the Business
  • Technology Savvy


We Own our Future

  • Solution Focused
  • Executing with Excellence


General

  • Ability to collaborate across the team and business unit, to support claims adjustment process
  • Demonstrated positivity with a passion to succeed
  • Ability to thrive through ambiguity, multiple competing tasks and changing priorities
  • Ability to maintain a balance of confidence and approachability