Manager,ClaimsandAdministration

Ensuring benefit adjudication and administration systems are working and programming of plan details are captured

Overseeing the efficient and timely response for adjudication and administration of benefit

Supporting and providing direction to team members to deliver effective resolution to member inquiries and any escalated member

Acting as a liaison between Team Leads

Ensuring regulatory requirements are followed & met for all processes and procedures across the Claims Management department.

Conducts a daily review of system related problems and issues that have been escalated by members

then takes effective action to resolve.

Ensures the system used for benefit adjudication is up to date including adjusting dollar values as rates of coverage change (or any benefit improvements).

Manages the turnaround times on adjudication and allocates resources based on the workload and/or advises Team Lead to reallocate resources to emergency or high priority situations.

Sets target metrics for claims adjudication and addresses any issues related to not meeting these targets.

Works with 3rd party TPP company to create new plan or member cards by completing required forms to set up the appropriate template and metrics for coverage.

Reviews monthly “unclaimed property” list provided by 3rd parties and assigns to a team member to confirm if cheque should be issued or if the 3rd party should move the unclaimed funds to the Bank of Canada.

Reviews monthly “terrorist watch” list received from insurance carriers and provides timely responses to any questions regarding members as requested.

Evaluates monthly “delisted clinic” listings received from insurance carriers and updates the system or distributes to the Claims Adjudicators to verify the claim against the list.

Conducts a review prior to issuing payments for each payment cycle to ensure proper deductions are made on payments and ensures related files are up to date.

Confirms Global is the plan sponsor and provides final signature on LTD applications.

Ensures that all plan accounts are set up and appropriate access permissions are granted to team members.

Manages the efficiencies and outputs of the call centre by reviewing the queue for “Hold” times

abandoned calls and understanding why there were abandoned.

Creates schedule to ensure sufficient coverage for Customer Care Specialists breaks

vacation and sick time coverage.

Acts as primary escalation point and the main contact when Customer Support Specialists are unable to resolve problems that arise through member emails or phone calls.

Oversees claims processes including pay direct

eligibility escalations

Manages payment cycles

final sign off for any cheque/EFT approvals

and rate updates within the system.

Coordinates with accounting and external stakeholders to ensure accurate and timely payments.

Supports tax processes (T4)

including corrections and communication with CRA and members.

and supports the Claims Management team to drive performance and engagement.

and ensures compliance with regulations and best practices.

Oversees onboarding and continuous development of team members.

Prepares and delivers communications to members

and internal stakeholders.