Dental Claims Consultant

The claims consultant will support the day to day accurate and timely handling of claims.

This includes managing escalated client issues, subrogation and claims involving legal case management, ombudsmen claims and client impact situations. Assisting and monitoring questions from analysts/seniors to promote accurate and timely adjudication of claims and directing further investigations where necessary. Serve as the Claims Representative and key participant for install meetings, client requested tours and demonstrations, training roll outs and change initiatives.

Also defined are competency levels for Teamwork, Customer Service, Giving and Receiving Feedback and Problem-solving and Decision-making.

What will you do:

• Understand systems, processes and other GB departments (Client Services, Group IT, etc.);

• Process and resolve escalated claims issues with Plan Sponsors, Plan Members, Business Development (Account Executives, Service Representatives), GBCCC and Member Impact Team(MIT). Understand systems, processes and other GB departments (Client Services, Group IT, etc.);

• Field and manage questions from the analysts/seniors

• Attend pre-install meetings and provide input from a claims adjudication perspective

• Investigate and resolve Ombudsman's cases, includes contacts with ombudsman's office and client (both verbal and written communication required);

• Successfully support claims team through change initiatives

• Lead and manage on-going training roll-outs

• Participate in client tours and claims demonstrations

• Serve as claims representative for Best Practice

• Run focus reports and contribute to management of results to ensure service standards are met

• Participate in departmental or GB projects as required

• Maintain confidentiality and clean desk policy at all times;

• Understand and adhere to Sun Life Financial Code of Business Conduct;

• Participate in the establishment of individual performance plans;

• Attend training as required;

• Contribute to the overall success of ACT; keep Customer satisfaction (our direct influence on the Customer Loyalty Index and Member Loyalty Index) in mind and remain conscious of our departmental commitments;

• Support on-going changes within the department and across business units.

What do you need to succeed:​

• Diploma in Dental Hygiene (CEGEP/College or University)

• Experience working in a dental clinic

• Strong knowledge of Group Insurance - Dental claims

• Customer service oriented

• Excellent communication skills both verbal and written

• Excellent problem solving skills

• Self motivated

• Team oriented Ability to work in a changing environment

• Strong decision making skills

• Open to receiving and giving feedback

• As this position is posted in several locations, we specify that bilingualism (French, English, both oral and written) is required for Quebec only to answer calls from English and French-speaking clients across Canada or worldwide
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Decision-making:

• Know how to navigate within and outside the department to resolve issues, conduct further investigation, identify inconsistencies in adjudication practices and identify training needs.

• Ensure that reference material inconsistencies are escalated to the appropriate area so that all documents are properly aligned.
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​Organizational Impact and Challenges:

• Know what Health and Dental Claims service standards are; ensure that claims/issues are managed or routed to the correct person/department to meet claim standards and satisfy clients need.
  

Notes/Unique Requirements:

• Overtime may be required as dictated by business need

• This role requires a set production and quality target range to be met daily

• Good knowledge of the special policies.