Job Description

We are seeking an experienced and detail-oriented Senior Claims Adjudicator to join our team. In this role, you will assess and adjudicate complex claims, ensure compliance with policy and regulatory requirements, and deliver fair, timely outcomes while supporting exceptional customer service. If you have a strong analytical mindset and a commitment to excellence, we'd love to hear from you.

About Guardian Life of the Caribbean Limited

Guardian Life of the Caribbean Limited leads the charge in Life, Health, and Pension solutions throughout the Caribbean Region. Our unwavering mission is to cultivate financial freedom for our stakeholders through transformative interactions, fuelled by the relentless power of technology. With innovation at our core, we strive to redefine the landscape of financial services, empowering individuals, and businesses alike to pursue their dreams with confidence and security.

The Senior Claims Adjudicator provides timely and efficient claims service to our customers. He/ She is responsible for the review and authorization of complex/ over limit claims in line with the established authorization limits and analysis of medical conditions in the claim payment process. Additionally, the position is required to provide training to the junior team members and facilitate the review and approval of overseas cases.

JOB RESPONSIBILITIES:

Claims Review and Authorization

• Co-ordinate the reviewing and processing of complex and local, regional and overseas claims in line with claims authorization limits and in accordance with performance standards. Assigning of complex claims to Claim Adjudicators

• Check and authorize all claims over the Claims Adjudicators limit and within Senior Claims Adjudicator’s limit.

• Liaise with the Medical Advisor on claims to determine overseas eligibility, pre-existing conditions, clarification of diagnosis or treatment and determination of medical necessity.

• Liaise with Aragón Agency and/or the Technical Officer Claims for Verification of Benefits for insureds seeking medical attention overseas.

2. Precertification Handling

• Check and authorize all precertification over the Processor’s limit and within Senior Claims Adjudicator’s limit.

• Execute large/complex precertification requests.

3. Overseas Case Management and Operations

• Determine overseas eligibility based on medical necessity and in consultation with the Medical Advisor and Technical Consultant.

• Liaise with Aragon Agency and/or the Technical Officer Claims and complete the Verification of Benefits process for insureds seeking medical attention overseas

4. Query and Escalation Resolution

• Ensure the prompt and accurate handling of client escalations.

• To be alert, decisive in time sensitive situations and displaying a solution oriented mindset when critical issues occur.

5. Procedure Update and Management

• To assist in the update and maintenance of claims processing procedures for the effective operations of Health Claims for Trinidad & Tobago and all other Territories under our purview.

• To share inputs on process and systems with other team members geared towards the continuous growth and development of the Team’s knowledge base.

6. Reporting

• Assist with the preparation of monthly reports including Aragon Report, Reinsurance and Large claims reports.

• To effectively use data to troubleshoot, identify trends/fraud and use this information to make recommendations geared towards cost containment and minimizing risk exposure.

7. People Management

• Assist with the supervision of the Claims Adjudicators in the absence of Team Leader – Health Claims.

• Assist with training of employees to optimize productivity and promote professional growth.

• Improve staff work processes: determine if inefficiencies exist and find solutions, aid in the development and implementation of recommendations.

• Actively participate in Weekly huddles with staff to discuss technical claims issues and any other matters pertinent to the claims adjudication process.

8. Provide Administrative and advisory support to the Senior Manager – Health Claims.

EDUCATION & EXPERIENCE:

• First Degree in Management or related field from a recognized tertiary educational institution.

• 5 C.X.C. / CSEC passes including English Language and Mathematics.

• 2 A’ Level / CAPE passes.

• LOMA 281, 291 and related parts ACS 101

• At least 2 years work experience in a Health Claims environment

• At least 2 years’ experience in processing claims.

ADDITIONAL REQUIREMENT:

As a regulated entity with obligations under the Know Your Employee guidelines, a Certificate of Character is required.

PERSON SPECIFICATION:

The Senior Claims Adjudicator must be articulate, confident and assertive with the ability to work with minimal supervision. He/ She must be very dedicated, trustworthy and must display strong work ethics. The incumbent must possess excellent communication and interpersonal skills with the ability to execute difficult conversations and be bold. He/She must be flexible and decisive when resolving issues. He/she must be able to engage in effective problem resolution strategies inclusive of the performance of root analyses and make recommendation as well as assist with the execution of solutions. He/She must be able to use data analytics as an effective tool for identification of trends and claims risks.