Health Claims Specialist - Remote Opportunity

About the Role

We are seeking a dedicated Health Claims Specialist to join our team at Great-West Lifeco. This is a fantastic opportunity for a motivated individual to work in a hybrid model, allowing you to balance your time between home and our Cork office. As a Health Claims Specialist, you will play a crucial role in ensuring the accurate assessment and payment of health claims, contributing to a seamless customer experience. This Health Claims Specialist remote position is perfect for someone who is passionate about health insurance and customer service.

What You'll Do

• Conduct governance audits for processed hospital and member claims in line with our Quality Assurance Strategy.
• Manage daily control report generation to ensure the effectiveness of the claims governance framework.
• Process local and overseas pre-approval requests according to established procedures.
• Act as the first line of defense against inappropriate billing, fraud, waste, and abuse within the claims process.
• Oversee team mailboxes, ensuring timely responses and actions within agreed KPIs.
• Identify and report ineffective controls or claims processes, providing recommendations for corrective actions to Senior Management.
• Analyze trends and patterns from audits and claims activity, supporting the implementation of remedial and preventive actions.
• Maintain up-to-date documentation (policies, procedures, guidelines) to ensure accuracy and relevance.
• Identify opportunities to streamline the claims process, supporting continuous improvement initiatives.
• Assist in producing and delivering training materials for TPA partners to ensure effective rollout of processes.
• Deliver exceptional customer service to members and providers, maintaining a strong customer focus in all interactions.

Requirements

• APA PMI qualification (or higher) is preferred.
• 1-5 years of experience in health insurance claims assessment.
• Strong knowledge of claims processes, assessment rules, and policy terms and conditions.
• Claims audit experience and understanding of governance principles are desirable.
• Excellent communication and interpersonal skills.
• Strong IT skills, particularly in Microsoft Excel (formulas, data analysis, reporting).
• Ability to manage a demanding workload and prioritize effectively.
• Proven ability to work independently and as part of a team.

Nice to Have

• Experience in health insurance with a good understanding of relevant legislation.
• Familiarity with multiple systems and advanced proficiency in Microsoft Office.
• Customer-focused mindset with a motivation to make a difference.

What We Offer

• Competitive salary and bonuses.
• Comprehensive benefits package including a Defined Contribution pension.
• Robust Learning and Development support.
• Wellbeing initiatives and support.
• Flexible hybrid working model.