Appeals Analyst

The appeals process is an opportunity for plan members to request a review of their case if they do not agree with the adjudication of their claim. Members must submit their appeal in writing explaining the individual circumstances that would warrant a reversal of decision, while respecting the provisions of the plan. It is the responsibility of the appeals analyst to research all the facts pertaining to each appeal and prepare a complete case summary which will be presented to the Appeals Committee. The appeals analyst is also responsible for the administrative procedures and correspondence related to the appeal process.

Key Responsibilities

  • Open all appeal files by assigning a case number, preparing the file and entering key information in the database
  • Review, research, investigate and analyse formal appeal cases
  • Prepare and draft analytical summaries of each case for review by the Directors of the Appeals Committee
  • Participate in Appeals Committee meetings by presenting the case summaries and providing plan design information
  • Review administrative cases and authorize resolution where required
  • Prepare correspondence in response to appeals. This includes the preparation and mailing of acknowledgement letters, status update letters, decision letters and follow-up letters.
  • Communicate with appropriate parties to obtain additional information. This includes representatives of the Plan Administrator, compensation advisors and the pension office.
  • Close and file appeals cases
  • Assist in the preparation of reports
  • Participate in the research of complex cases or issues
  • Build and develop internal and external relationships

Requirements

  • University or college degree
  • Minimum 3 years of experience in a related field
  • Fluent bilingualism (French/English) is essential for both written and verbal communications
  • Experience in operating word processing and presentation software (i.e. MS Word, Excel, PowerPoint)
  • Ability to write, edit and revise correspondence and correct its content, grammar, style, spelling and presentation in both official languages
  • Ability to manage multiple and conflicting priorities within a busy work environment
  • Ability to analyse and synthesize data from various and multiple sources
  • Ability to work effectively under pressure, work as part of a team and individually
  • Solution oriented
  • Customer focused
  • Knowledge of the health insurance industry and the Public Service Health Care Plan is an asset

Interested candidates should send a resume and cover letter to hr@pshcp.ca.