Health Claims Benefits Specialist

The Opportunity:

We are a leading Canadian financial services co-operative committed to being a catalyst for a sustainable and resilient society and our team is essential to deliver on this strategy. That’s why we prioritize our people, to ensure we provide a strong culture and development opportunities which enables our team to thrive and to live our purpose. The best part is that you will work with people that care passionately about you, our clients, and our communities.

Our Group Benefits team is a leader in our target markets through service excellence and innovative technology and products. Influenced by our co-operative values, our team of experts work collaboratively with clients to deliver solutions that meet their business needs.

The Health Claims Benefits Specialist proactively audits Extended Health and Dental claims to detect and prevent Benefits Fraud. You will identify and investigate fraudulent activity and liaise with internal partners, providers, and vendors. You will participate in CLHIA fraud initiatives and develop business procedures based on data outcomes. You will also be the first point of contact with Allianz to ensure a seamless process for emergency out of country claims.

How you will create impact:

• Perform audits on claims submissions and verify appropriate documentation and validation of services incurred. Develop summary reports based on the collection of evidence and communicate findings to the affected parties.

• Investigate claiming patterns and resolve disputes around claims settlements.

• Maintain successful relationships with the out of country provider, Allianz, plan administrators and insured members.

• Review files, accurately record activity and report activity to appropriate associations where required.

• Develop and present fraud awareness programs related to audit outcomes and claiming patterns.

• Correspond audit outcomes to plan members.

• Ensure the highest degree of accuracy and attention to detail is maintained, while recording errors on the appropriate database.

• Participate in CLHIA working groups and recommend change to business process based on learnings.

How you will succeed:

• You have an innovative mindset to improve operational efficiencies and the ability to influence change, with a primary focus on client needs.

• You use critical thinking skills to recognize and differentiate assumptions, evaluate arguments, draw conclusions, and proactively propose solutions.

• You have strong communication skills to clearly convey messages.

• You build trusting relationships, provide guidance to and support internal and external clients.

To join our team:

• 3 to 5 years experience in Group Benefits

• Completion of post-secondary technical or industry equivalent (1–2-year program) are recommended.

• Working towards LOMA (FLMI) designation.

• International Claims Association (ICA) designation would be considered an asset.

• Possess a good understanding of EHC and Dental products, as well as the claim adjudication process.

What you need to know:

• You will handle sensitive information where a high degree of confidentiality and discretion is required.

• You will be subject to a Background check as a condition of employment.

What’s in it for you?

• Training and development opportunities to grow your career.

• Flexible work options and paid time off to support your personal and family needs.

• A holistic approach to your well-being, with physical and mental health programs and a supportive workplace culture.

• Paid volunteer days to give back to your community.

• A comprehensive total rewards package, including competitive salary, bonus, pension and benefits.