Senior Claims Adjudicator Jobs

Familiarization with the requirements of the appropriate provincial/state legislation and/or regulations related to the type of claim being reviewed.

Perform all necessary benefit calculations and ensure all related activities are in compliance with provincial/state statutory and internal standards.

5 – 7 years experience adjudicating complex claims, including contestable claims;

Knowledge of the interpretation and application of claims adjudication regulations across the United States, knowledge of Canadian regulations an asset

Advanced verbal and written communication skills to effectively communicate with internal and external customers/partners and vendors.

Strong analytical skills for research, review and assessment of claims.

Job Requirements (Education, Experience, Knowledge, Skills And Proficiencies)

You will have adjudication knowledge and experience

Create a white glove customer experience for our Claimants

Manage ongoing claims by requesting further medical, financial documentation or investigations as required and consult with specialists in all areas.

Make decisions on claim benefit eligibility determination and communication decisions to stakeholders

University degree in any discipline or equivalent work experience.

Be responsible for other duties as may be assigned from time to time by Management

Verify data entry for accuracy and completeness

Perform data entry of claims sent to dental consultant is added and confirmed on a spreadsheet

Analytical skills to research review and assess claims

Strong verbal and written communication skills

Strong attention to detail with exceptional organization skills

Act as the key point of contact for property management and operations departments in response to claims.

Canadian Risk Management (CRM) designation considered an asset.

A competitive salary commensurate with skills and experience

Manage internal claims within a corporate self-insured retention (SIR) model.

Minimum of three (3) years of claims handling experience.

Excellent written and verbal communication skills.

Assist in the management of claims

Manage, organize, and retain insurance claims records (electronic files), submissions and other correspondence

Manage the appropriate level of resources across the assigned territory

Manage the quality and appropriateness of client service agreements

Key Duties/responsibilities Include, Without Limitation, The Following

Document and communicate claim activity to clients timely and effectively

Review short term disability applications to determine initial eligibility and entitlement to benefits based on medical and contractual requirements

Oversee case until return to work or refer claim internally for case management

Minimum two years experience in a medical, benefits administration, or claims setting; and

Assess functional abilities to determine work-readiness and coordinate suitable return to work

Strong assessment and decision-making skills

Ability to effectively manage and resolve conflict

Knowledge in life insurance and experience in life and disability claims management would be an asset.

Experience related to disability claims management is preferred.

Plan, implement and evaluate sound case management principles.

Knowledge of the insurance benefit industry is considered an asset.

Must possess excellent knowledge and experience with Microsoft Word, Access, Excel, and PowerPoint.

Experience or knowledge with Fineos is an asset.

Handle relationships with internal and external partners involved in management of customer claims

Acquire and maintain appropriate provincial adjuster licenses and comply with continuing education requirements – where required

Communicate policy coverage and benefits to customers

Identify and report on any suspicions of fraud or financial irregularities in line with existing internal and external requirements and procedures

CIP or FCIP Industry designation or other relevant professional insurance qualification

University Degree or College Diploma or equivalent Property technical work experience

Familiarization with the requirements of the appropriate provincial/state legislation and/or regulations related to the type of claim being reviewed.

Perform all necessary benefit calculations and ensure all related activities are in compliance with provincial/state statutory and internal standards.

5 – 7 years experience adjudicating complex claims, including contestable claims;

Knowledge of the interpretation and application of claims adjudication regulations across the United States, knowledge of Canadian regulations an asset

Advanced verbal and written communication skills to effectively communicate with internal and external customers/partners and vendors.

Strong analytical skills for research, review and assessment of claims.