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About the role
- Drug Technical Claims Consultant providing technical support to internal and external customers in claims payment processes. Ensuring compliance with contractual policy provisions and competent claim adjudication.
Responsibilities
- Ensure that Drug Claims are handled in accordance with contractual policy provisions by establishing sound business rules/administrative guidelines for claims adjudication
- Provide technical expertise to internal and external customers to facilitate claims payment, resolve escalated complaints, manage new issue support etc.
- Provide technical expertise for the development of new product offerings, claim initiatives and client customizations that relate to the drug benefit
- Attend client meetings as required
- Attend litigation/arbitration sessions in court
- Accurate release of claims payments up to $80,000.00
- Ensure DIN files and drug plans are updated as new drugs, formulary and pricing information is introduced
Requirements
- Post-Secondary education in a related field - pharmacy or nursing background would be an asset
- Thorough knowledge of the Claims admin/payment systems including GIPSY, GRID, Clients II, ESC and V3
- Computer proficiency with MS Word, Excel, Powerpoint
- Understanding of Federal and Provincial Health Care legislation would be an asset
- Excellent understanding of claim administrative procedures, contractual provisions and drug product offerings
- Excellent written/oral communication/customer service skills
- Good presentation and negotiation skills
- Strong analytical, research, problem-solving and decision-making skills
- Effective project management capabilities
- Ability to review and analyze critical data to make formal recommendations for process improvements
- General understanding of medical terminology, diseases and drug formularies
- Comfortable speaking with external parties such as pharmacists, health care providers, drug manufacturers, government agencies, plan members and plan sponsors etc.
- Must be able to decipher health industry information and understand how it relates to Group Benefits' plans
- Proven ability to manage/schedule a fluctuating, unpredictable workload
- General understanding of all Group Benefits departments
Benefits
- Health insurance
- Dental insurance
- Mental health support
- Vision insurance
- Short- and long-term disability insurance
- Life insurance
- AD&D insurance coverage
- Adoption/surrogacy benefits
- Employee/family assistance plans
- Retirement savings plans
- Pension plan
- Share ownership plan with employer matching contributions
- Financial education and counseling resources
- Paid time off including holiday, vacation, personal, and sick days
- Full range of statutory leaves of absence
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