Appeals Analyst

The PSHCP Administration Authority’s mandate is to ensure that benefits and services to plan members and their covered dependants are delivered in a manner that ensures the effective and efficient administration of the plan. The PSHCP Administration Authority is responsible for monitoring the performance and compliance of the plan administrator (Sun Life Financial), considering appeals from plan members and communicating with plan members, as well as other responsibilities.

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.