BMO Financial Group Claims Examiner, BMO Life in Ontario, Canada

Description:

Claims Examiner is accountable to provide effective & efficient service and deliver the desired experience to policyholders, brokers, agents, claimants and other internal departments by answering incoming calls and managing general questions for a varied range of insurance products. In addition, this role will provide administration support in setting up new incoming claims, ensuring that all required information is received or requested. The Claim Examiner will answer administration questions (premium payments, eligibility) from policyholders, brokers, third party administrators and claimants related to the Group Insurance Products (LTD, STD, Life Insurance, CI & AD&D).

The Claims Examiner will also adjudicate Direct Life (up to $40,000) and other claims including Hospital cash and funeral coverage as assigned and within authority level. Claims range in complexity and may take between 15 minutes to complete, depending on contract and medical validation. Effective claims management and keeping contractual promises are critical to the ongoing success of BMO Life Assurance and for meeting the brand promise of BMO Financial Group.

Claims Examiner at BMO Life Assurance administer the initiation and set up of claims for Life, Accidental death & dismemberment, well woman, individual disability insurance, critical illness and group insurance products. Claim Examiner will produce reports including time service, Group experience reports and monthly reports for all product lines. Claims Examiner is required to have extensive product knowledge related to all the offerings from BMO Life Assurance as well as excellent customer service skills.

  • Claims Servicing

  • Claims Adjudication

  • Administrative Support

  • Risk Management

Claims Servicing

  • Answer incoming calls by policyholders, brokers, agents, beneficiaries and claimants in an efficient and effective manner delivering the desired client experience by assisting with general questions and initiating claims forms for all products

  • Answer administrative questions from Group policyholders, insured’s, brokers, third part administrators and claimants

  • Address any claimant or policyholder issue as part of the conversation, escalating as required for any complaint situation

  • Acknowledge receipt of new claims and request outstanding information for new claims, incomplete claims and approved claims to support processing and monitor ongoing to ensure all information is received

  • Set up new incoming claims in the appropriate system for reported claims as required based on the client need & product requirements, and send out applicable acknowledgement letters

  • Advise POS for Agency claims when a death occurs to stop premium payments

  • Partner with business partners in Agency and Direct to initiate new claims set up, monitor workflow to ensure that claims meets servicing turnaround time for adjudication process

  • Assign new claims to Claims Specialists as per workload allocations defined by the Director, Claims

  • Provide support to Claims Specialists with any additional information requests, including information follow-ups to policyholders to deliver overall required experience

  • Maintain relationships with internal and external business partners, third party administrators, agents and brokers to support effective claims operations and workflow

Claims Adjudication

  • Adjudicate assigned Direct Life (valued $40,000 and under), Hospital cash, fracture coverage and funeral coverage by performing the following key activities, including but not limited to:

  • Reviewing the claim file and investigating claims details to determine the validity of the claims

  • Conducting telephone interviews with insured’s, beneficiaries, agents and brokers, as appropriate

  • Consulting as appropriate with internal medical consultants and legal resources

  • Analyze financial information to determine financial liability

  • Making decisions regarding investigative actions including medical investigations, that may be required for the particular situation

  • Develop and document detailed case management action plans, both initial and ongoing

  • Making eligibility decisions to approve or deny or making recommendations if outside authority level

  • Re-evaluating claims that are in first appeal to approve or uphold past decisions and preparing liability recommendations for first level appeals

  • Analyzing financial information and contract to determine financial liability on claims

  • Making decisions to approve or deny or making recommendations, if outside authority level, including detailing appropriate action plan and rationale

  • Communicating decisions both verbally and in writing, as appropriate to the claim type

  • Signing to release payments on approved claims according to established policies

  • Manage assigned case load in an effective manner, escalating any issues or concerns, to ensure ongoing effective claim operations

  • Address any claimant or policyholder issue as part of the conversation, escalating as required for any complaint situation

  • Maintain effective relationships with claimants, policyholders, employers, third party administrators and beneficiaries to deliver the desired client experience and retain clients and employers for BMO Life Assurance

Administrative Support

  • Request the set up vendors, health care providers, rehabilitation consultants and other service providers in the expense payment system

  • Process approved expense payments for the department through required system and deliver payment request to Accounting to support effective claims operations

  • Manage daily cheques for group claims by printing off cheque run information and distributing it to appropriate Claims Specialists

  • Manage department supplies, ordering as required to ensure that all supplies are available for operations

  • Scan identified claim files as part of front-end imaging

  • Manage the cataloging of files sent monthly to offsite storage and coordinate with the Office Services area

  • Recall files from offsite storage as required by the claim specialist or in relation to litigation claims activity

  • Provide business partners with monthly copy of the expense payment report

Risk Management

  • Follow established policies & procedures including authority and signing authority for BMO Life Assurance and the reinsurer to manage the risks inherent in claims operations and escalate any issues or concerns

  • Participate in quality reviews addressing any issues identified to help reduce risk inherent in claims operations

  • Follow appropriate guidelines in addressing client concerns and complaints, including documentation of claims to the Complaint’s Ombudsman

  • Adhere to all aspects of First Principles our code of Business Conduct and Ethics including individual accountability as it relates to potential conflicts of interest, safeguarding of customer information, trading in securities, anti-money laundering, privacy and disclosure of outside business activities

Qualifications:

Knowledge

  • 1-3 years of customer service and administrative experiences in the Life Insurance industry; Previous customer call centre experience is preferred

  • High school diploma or College degree

  • Bilingual Business level English and French fluency, written and verbal

  • Knowledge of insurance products, contracts and benefit plans (all individual, disability and group products)

Skills

  • Customer Service skills (Working)

  • Communication skills (Working)

  • Influence skills (Working)

  • Organization skills (Working)

  • Multi-tasking skills (Working)

We’re here to help

At BMO we have a shared purpose; we put the customer at the centre of everything we do – helping people is in our DNA. For 200 years we have thought about the future—the future of our customers, our communities and our people. We help our customers and our communities by working together, innovating and pushing boundaries to bring them our very best every day. Together we’re changing the way people think about a bank.

As a member of the BMO team you are valued, respected and heard, and you have more ways to grow and make an impact. We strive to help you make an impact from day one – for yourself and our customers. We’ll support you with the tools and resources you need to reach new milestones, as you help our customers reach theirs. From in-depth training and coaching, to manager support and network-building opportunities, we’ll help you gain valuable experience, and broaden your skillset.

To find out more visit us at https://bmocareers.com .

BMO is committed to an inclusive, equitable and accessible workplace. By learning from each other’s differences, we gain strength through our people and our perspectives. Accommodations are available on request for candidates taking part in all aspects of the selection process.

Job Field:

Insurance & Assurance

Job Schedule:

full-time

Primary Location:

Canada-Ontario-Toronto