Claims Representative – Medical Claims

About the role

Cigna Healthcare is looking for a Claims Representative to analyse and adjudicate medical, dental and vision claims for clients. The role works to meet personal and team productivity and quality goals, and involves accurate handling of complex cases.

Key responsibilities

• Analyse claims for client medical costs and adjudicate medical, dental and vision claims in line with policy terms and conditions.
• Analyse reimbursements against contract agreements and assess, code and calculate them using a computerised claims processing system.
• Pass communications to the communication team so that issues with stakeholders can be solved or prevented.
• Monitor turnaround times and flag to the supervisor when claims cannot be settled within required time scales.
• Take ownership of complex cases and keep knowledge up to date on medical information, policies and processes through training.
• Report inaccuracies in files to the team leader or departmental head and respond to enquiries on plan design, eligibility and claims status, aiming for first-call resolution.
• Carry out ad hoc tasks as needed and work independently, escalating appropriately when required.

Required profile

• Diploma or degree in a relevant field.
• Previous experience handling medical claims in a health insurance or healthcare provider environment is an added advantage.
• Strong working knowledge of English; French is an added advantage.
• Desirable: previous analytical role with strong numerical ability, accuracy and attention to detail.
• Customer-focused, able to balance accuracy, service and operational requirements, with integrity and discretion with confidential information.

Required skills

• Good analytical and problem-solving skills.
• Comfortable learning and working with computer-based applications and claims processing systems.