Senior Claims Adjudication Officer

Summary

Guide, mentor and coach team members within the Claims Unit to complete work assignments and achieve unit targets. Assist with resolving operational and team-related issues to support the efficient and accurate processing of claims, adherence to company policies and regulatory requirements, and the overall delivery of exceptional client service. Work with team and Unit Management to identify areas for improvement within Claims adjudication processes, procedures and service standards, and assist with implementing improvement initiatives as required. Review claims and disbursement documentation for accuracy and compliance with company policies and regulatory requirements. Train, provide performance feedback for, and encourage team members to develop strong client relationships. Collaborate with various internal and external stakeholders to resolve Claims-related client queries, concerns and needs promptly and effectively to help promote client satisfaction and loyalty.

Responsibilities

• • Guide, mentor and coach team members to ensure assignments are completed and Unit targets achieved.
• • Coordinate workload distribution, prioritise tasks, and ensure accurate and timely processing of claims, response to client queries, needs and provision of information.
• • Conduct desk audits weekly to ensure agreed standards for accuracy are maintained.
• • Monitor claims processing activities within team and guide team staff to maintain payment standards and compliance in accordance with unit/divisional targets, corporate goals, company policies, procedures, standards of service, and other relevant regulatory requirements and business laws.
• • Monitor activities within team to ensure prompt and effective communication with claimants, addressing inquiries and concerns in line with company policy and service level standards.
• • Monitor and review client queries, requests and complaints and query handling activities within unit to maintain client satisfaction levels; in collaboration with Unit Management and make recommendations to enhance the claims experience.
• • Continuously monitor claims processing to ensure compliance with company policies, standards of service, procedures and relevant business legislation, healthcare and other relevant regulatory requirements.
• • Consult with Unit Management and recommend changes to processes and procedures to drive effective claims adjudication.
• • Contribute to the development and execution of claims handling and processing strategies to align Unit work and team performance to overall company strategy, goals and objectives.
• • Prepare and submit reports monthly.
• • Perform any other job-related duties assigned from time to time.

Required Skills

• • Excellent supervisory skills and sound knowledge of industrial relations.
• • Proficiency in CAPSIL software, and other business tools, including word processing and spreadsheet applications; proficiency claims management software and tools would be an asset.
• • Working knowledge of fraud detection/prevention practices.
• • Proficiency in the use of computer software packages such as word processing and spreadsheet applications.
• • Sound knowledge of insurance products, processes, procedures and industry best practices.
• • Sound knowledge of policy provisions and laws governing Life Insurance contracts.
• • Knowledge of Reinsurance Underwriting.
• • Working knowledge of basic accounting principles.
• • Working knowledge of local Data Privacy Acts.
• • Excellent verbal and written communication and listening skills, with the ability to communicate complex information clearly and persuasively.

Qualifications

• • A Bachelor’s Degree in Business Administration, Management Studies, Client Service Management or an equivalent qualification from a recognised tertiary institution.
• • Minimum three (3) years’ working experience with at least one (1) year spent at the supervisory level in the finance industry, preferably the operations division of a life or health insurance company.
• • Life Office Management Association’s (LOMA) Associate Customer Service (ACS) designation would be an asset.
• • Associate in Claims (AIC) designation would be an asset.
• • Supervisory or Management training is highly desirable.

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