Claims Representative - Provider Services

Requirements

Education

• Bachelor’s degree in a Business, Mathematics, Economics, Statistics or related field.
  

Languages

• Proficiency in English required.
  
• Additional languages (French, Portuguese) are an added advantage.
  

Skills and Professional Attributes

• Strong decision making capability, with the ability to act based on available information.
  
• Proficiency working with numerical data and structured information.
  
• Ability to navigate multiple systems and adapt quickly to new tools and processes.
  
• High attention to detail, with consistent accuracy across repetitive tasks.
  
• Reliable adherence to processes, documentation standards, and audit requirements.
  
• Ability to sustain quality and productivity expectations in a high volume environment.
  
• Strong teamwork orientation and willingness to support colleagues when needed.
  
• Demonstrate discretion when handling confidential medical information.
  

• Process provider claims against policy and benefit rules, delivering decisions that meet quality and turnaround time standards.
  
• Validate and reconcile claim data across Administration, Workflow, and CRM platforms; ensure completeness, coding alignment, and internal consistency.
  
• Maintain full compliance with confidentiality, data protection, medical privacy, and audit documentation requirements.
  
• Identify and escalate claims issues in a concise context meeting both customer and provider satisfaction standards.
  
• Communicate relevant escalation updates to internal partners in a clear, structured, and timely manner.
  
• Monitor claim trends, anomalies, or workflow inefficiencies and communicate these to the Supervisor for action.
  
• Manage assigned claim queues proactively, maintaining throughput during routine and peak periods.
  
• Contribute to team cooperation, knowledge sharing, and a professional working environment.
  
• Execute any additional responsibilities assigned by the Supervisor.