Customer Service Representative

To evaluate and enforce insurance claims in line with policy terms, SOPs, and client instructions, ensuring accurate and timely data entry, adherence to cost containment measures, and exceptional service delivery via both email and phone.

Job Purpose:
To evaluate and enforce insurance claims in line with policy terms, SOPs, and client instructions, ensuring accurate and timely data entry, adherence to cost containment measures, and exceptional service delivery via both email and phone. The role involves investigating and escalating potentially fraudulent claims, addressing complaints, and supporting claim-related queries while maintaining compliance with company guidelines. Flexibility to work outside standard hours and handle ad-hoc tasks is essential to meet operational needs.

Key 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
• Perform data entry of bills based on SOPs
• 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
• Handle calls/emails or other communication in relation to claims
• Perform Adhoc tasks as requested by supervisor

Experience and Skills

• Minimum of 1 year of experience in either insurance claims processing, customer service, or a related field.
• Familiarity with policy wording, insurance claims procedures, and relevant SOPs is desired
• Proven ability to handle high-volume claim reviews and data entry with accuracy and efficiency.
• Experience in investigating and escalating potentially fraudulent claims is an advantage.
• Attention to Detail - Strong focus on accuracy in data entry, documentation, and validating service charges.
• Customer Service: Excellent communication skills (both English and French) to ensure clients and customers receive high quality professional service.
• Time Management: Ability to meet deadlines, prioritise tasks, and handle ad-hoc responsibilities as needed.
• Interpersonal Skills: Ability to work collaboratively with team members and escalate issues appropriately when necessary.
• Communication: Proficiency in handling communication via email and phone.
• Ability to work under pressure.