IOH Member Claims Representative

Role Overview

As a Claims Representative, you review medical, dental and vision expenses and decide whether they qualify for reimbursement under the member’s plan. Your work combines careful assessment, accurate processing and timely responses to enquiries, helping clients receive decisions that are consistent with policy terms and service commitments.

Key Responsibilities

• Assess medical, dental and vision claims against applicable policy provisions and contractual arrangements.
• Verify claim information, assign appropriate codes, calculate eligible reimbursements and record decisions in the claims system.
• Manage work to meet individual and team targets for accuracy, quality and productivity.
• Track pending claims against required turnaround times and alert your supervisor when a deadline may be missed.
• Take ownership of complex cases, investigating relevant details and handling each matter with care and precision.
• Respond within agreed timeframes to questions about plan design, eligibility and claim progress, resolving enquiries at first contact where possible.
• Share relevant case information with the communications team to address or prevent stakeholder concerns.
• Identify discrepancies in claim files, raise them with the appropriate team lead, and keep your knowledge of medical information, policies and procedures current through ongoing training.

Requirements & Qualifications

• Diploma or degree in a relevant discipline.
• Experience processing medical claims in a health insurance or healthcare provider setting is an advantage.
• Strong English communication skills for working with internal and external stakeholders; French proficiency is beneficial.
• Sound numerical ability, accuracy and attention to detail, ideally supported by experience in an analytical role.
• Good judgement and problem-solving skills when reviewing information and making claim decisions.
• Customer-focused approach that balances service quality with policy accuracy and operational needs.
• Ability to work independently, manage responsibilities and escalate issues appropriately.
• Adaptability when processes, priorities or systems change, and confidence using computer applications and claims platforms.
• Integrity and discretion when handling confidential medical and customer information, along with a collaborative willingness to share knowledge.