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.
- 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
- 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 firstname.lastname@example.org.