Claim Assessor

To perform thorough and accurate evaluation, validation, and processing of claims in accordance with policy terms, standard operating procedures, and company guidelines.

Job Purpose

To perform thorough and accurate evaluation, validation, and processing of claims in accordance with policy terms, standard operating procedures, and company guidelines. The role involves ensuring cost-efficiency, maintaining compliance, and delivering exceptional service to clients and customers. This position upholds fairness, integrity, and professionalism in claims management, while contributing to the organisation’s commitment to operational excellence.

Key Tasks & Responsibilities

• Evaluate and enforce claim benefits and limitations based on the understanding of the applicable policy wording or client direction as documented in the process flows/SOPs
• Qualify claims/ bills for payment.
• Contribute to cost containment efforts by validating bills for services rendered, authenticity and reasonable and customary charges.
• Direct bills to the appropriate internal financial process.
• Ensure the client/customer is treated fairly and that the customer receives excellent service in accordance with industry and company guidelines.
• Investigate potentially fraudulent claims and escalate them to supervisor.
• Be flexible to work outside local office hours when required.
• Support department with information on how to proceed with the claim and provide clarifications and support when needed.
• Collect accurate information and documents to proceed with a claim, make appropriate decisions and complete tasks based on SOPs.
• Analyse a claim made by a policyholder to establish whether it satisfies the policy conditions, request information, follow ups when needed based on SOPs.
• Handle any complaints associated with a claim based on provided guidelines and SOPs.
• Escalate claims to direct superior when experiencing a situation outside the SOPs.
• Conduct outbound calls/emails or other communication in relation to claims
• Perform Adhoc tasks as requested by supervisor.

Skills and Qualifications

• Minimum Higher School Certificate (HSC) or equivalent.
• At least 3 years of experience in customer service or a related field, preferably within the insurance or healthcare industry.
• Strong written and verbal communication skills in both English and French, with fluency in oral and written formats.
• Flexibility to adapt to shifting priorities and work outside regular office hours when required.
• Proficiency in using standard office software (e.g., Microsoft Office Suite) and claim management systems.
• Strong analytical skills to assess claims accurately against policy terms and standard operating procedures.
• Attention to detail and the ability to handle large volumes of data with accuracy.
• Demonstrated ability to provide exceptional customer service while maintaining professionalism and empathy.
• Strong problem-solving skills to address client inquiries and complaints effectively.
• Strong teamwork skills, with a willingness to support colleagues and share knowledge.
• Capacity to handle confidential information with discretion.