Claims Adjudicator – Health & Dental Insurance (Entry-Level)

Job Description (Professional Version)

Candidate Profile

• Degree/Certifications Required: Bachelor’s degree in Business or a related field.
• Years of Overall Experience: 0–2
• Preferred Candidate Background: The successful candidate will support the affinity market for health and dental, catering to member needs.

Project Overview The candidate will assist with Business As Usual (BAU) activities. The group is transitioning from a legacy system to a cloud-based system and requires additional resources to process health and dental claims.

Performance Measurement

Performance will be measured based on:

• Productivity (number of claims processed per day)
• Quality of claims processing

Selling Points of Position (CVP)

The successful candidate will have opportunities for growth and the potential to transition into a permanent role. They will gain valuable insights into how the affinity market works. This position can lead to other opportunities where business analysis and customer service acumen can be further developed.

Summary of Day-to-Day Responsibilities The Claims Adjudicator is accountable for handling claims in accordance with high service standards to meet or exceed client expectations. The Adjudicator is required to make determinations that may affect a member’s entitlement to benefits and/or the amount of benefits 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.

• Assess highly complex health/dental claims in accordance with contract provisions, taking initiative and ensuring empowered decision-making is a key component of the process.
• Assume ownership of assigned claims, understanding the urgency of specific cases and effectively prioritizing work accordingly.
• Establish and maintain high-quality customer service within turnaround times, using influence with internal and external clients to meet all pre-established service standards and delight customers.
• Commitment to financial efficiency and continuous improvement targets, as required.
• Commitment to improving NPS (customer) scores based on overall goals.
• Sound knowledge and ability to apply appropriate risk management tools and techniques.
• Actively participate in projects that improve the effectiveness and efficiency of claims practices in alignment with a culture of continuous improvement.
• Manage all issues and requirements related to claims to achieve customer/claim resolution, handing off only when appropriate (claims adjustments, technical decisions).

Must-Have Hard Skills

• Claims review and adjudication skills – ability to review insurance claims, verify policy coverage, and determine settlement eligibility
• Exceptional communication skills – proficient in both verbal and written communication for diverse internal and external audiences
• Proficiency in Microsoft Office 365 – strong working knowledge of the Office 365 suite
• Detail-oriented with quick assessment skills – strong attention to detail for reviewing receipts, extracting data, and accurate data entry
• Analytical skills for claims evaluation
• Ability to work independently and collaboratively in a fast-paced environment

Soft Skills

• Strong customer service focus
• Ability to take initiative
• Excellent interpersonal skills
• Ability to interact with individuals at all levels to ensure customer satisfaction

Nice-to-Have Skills

• Bilingual English/French is an asset
• Previous claims adjudication or insurance/healthcare experience
• Call center or data processing experience
• Experience working with legal, medical, or external service providers

The expected base salary range for this position is $17 – $18 per hour, depending on experience, skills, and internal equity.

The Company offers a total rewards package in accordance with all applicable federal, provincial, and local laws and requirements. Benefit eligibility and offerings vary based on role, employment status, and work location.

For contractor positions, benefits are limited to those entitlements and protections required by applicable law, which may include (as applicable) vacation pay, public holidays, leaves of absence, and other legally mandated benefits or payments.

We may use AI-enabled and/or automated tools to support parts of our recruitment process, including application screening, interview scheduling, and candidate communications. These tools are used to enhance consistency and efficiency. A