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About the Role
The Health Claims Adjudicator reviews, adjudicates, and processes group extended health and dental claims according to policy guidelines, industry standards, and applicable provincial legislation. Success is measured by accuracy, communication, productivity, and recommending process improvements.
Responsibilities
- Adjudicate health and dental claims in accordance with plan provisions, policies, and contractual requirements.
- Review Cost Plus and Out‑of‑Country claims to ensure coverage rules and eligibility criteria are applied correctly.
- Interpret plan provisions, policies, and contracts to support accurate benefit decisions and compliance with regulatory and organizational standards.
- Coordinate tasks and oversee designated workloads in multiple adjudication queues and shared email inboxes for prompt claim processing.
- Prioritize tasks to meet established service level agreements, productivity targets, and quality expectations.
- Communicate professionally with internal partners, providers, and members to clarify coverage, resolve issues, and explain adjudication outcomes.
- Apply critical thinking and sound judgment to identify process improvement opportunities and provide rationale for enhancements.
- Support departmental initiatives and projects that promote operational efficiencies and continuous improvement.
Requirements
- Degree in health science, insurance, business administration, or related fields.
- 1 year of experience in the group health and dental benefits field.
- Proficient in data entry with demonstrated attention to detail and accuracy.
- Strong written and verbal communication skills for professional interactions with clients and providers.
- Critical thinking abilities and an inquisitive mindset to review and refine policy guidelines.
- Subject to a Background check as a condition of employment.
Skills
- Data entry
- Attention to detail
- Accuracy
- Written communication
- Verbal communication
- Critical thinking
- Problem-solving
- Teamwork
- Knowledge sharing
Location
- Canada
Work Type
- Hybrid
- Regular Full-Time
Experience Level
- 1 year of experience in group health and dental benefits field
Education Level
- Degree in health science, insurance, business administration or related fields
- GBA (Group Benefits Associate) designation (asset)
- ALHC (Associate, Life and Health Claims) designation (asset)
Salary/Compensations
- $43,550 - $72,583
Benefits
- Training and development opportunities
- Flexible work options
- Paid time off
- Physical and mental health programs
- Supportive workplace culture
- Paid volunteer days
- Competitive salary
- Incentive programs
- Group retirement savings plans
- Pension
- Health and wellness coverage
- Dental coverage
- Disability coverage
- Life coverage
- Mental health support
- Employee assistance program
About the Company
- CLIC is a leading Canadian financial services co-operative committed to being a catalyst for a sustainable and resilient society.
- The Group Benefits team is a leader in its target markets through service excellence and innovative technology and products.
- The team's collaborative approach is influenced by co-operative values to deliver solutions that meet client business needs.