ABOUT US |
A leading regional player in the retail insurance sector, Coralisle Group Ltd., with over 600 employees and offices in Bermuda, the Bahamas, Barbados, the British Virgin Islands, the Cayman Islands, Turks & Caicos Islands, Anguilla, Antigua and Barbuda, Montserrat, Dominica, St. Lucia, St. Vincent, Saint Maarten, Grenada, Trinidad and Tobago, Guyana, Curacao, Aruba, Jamaica and Belize, we and offers a complete range of premier financial and insurance services to our individual and corporate clients. We know that our products make a real difference to our clients and their families.
THE ROLE |
Reporting to the Operations Manager, Assistant General Manager, Director of Operations, you will be responsible for the overall leadership, management, and strategic oversight of the Claims Department in Bermuda, ensuring the accurate, timely, and cost-effective adjudication of medical, dental, vision, life, and disability claims in accordance with Company policies, contractual obligations, regulatory requirements, as well as service standards. You will manage claims operations, review complex and high-dollar claims, monitor claims quality and departmental performance, and develop operational processes that support efficient administration and effective cost management. You will serve as the primary subject matter expert for claims operations and medical claims management and work collaboratively with internal departments, healthcare providers, external vendors, brokers, consultants, and regulatory bodies to support the Company's strategic objectives.
In addition, you may attend Bermuda Health Council meetings, healthcare industry forums, provider meetings, and stakeholder engagement sessions. You will also support technology initiatives, process improvement projects, fraud prevention efforts, and other strategic assignments that contribute to the efficient operation and ongoing success of the Company. Other duties and responsibilities include:
- Oversee the overall workflow, productivity, quality, and operational effectiveness of the Claims Department in Bermuda and EC territories.
- Monitor inventory levels, claims processing turnaround times, auditing results, and departmental performance metrics to ensure established objectives are achieved.
- Communicate daily inventory, operational risks, trends, and staffing concerns to the Director of Operations or designate.
- Ensure all industry reference materials, coding resources, fee schedules, and processing guidelines are maintained and updated.
- Ensure follow-up requests are managed effectively and in a timely manner.
- Report claims exceeding established timetables and provide recommendations and management for resolution.
- Maintain accurate employee and departmental documentation.
- Conduct regular quality assurance reviews, desk audits, and operational assessments.
- Review high-dollar and complex claims, including those meeting external medical review criteria.
- Review supervisory-level claim determinations and provide escalation support as required.
- Review and respond to claims-related inquiries from staff and other departments and clients in a timely manner.
- Review requests for claim adjustments, reconsiderations, and payment exceptions.
- Develop, implement, and maintain claims policies, procedures, workflows, and internal controls as required.
- Monitor performance standards, goals, objectives; report achievements and addresses underperformance.
- Ensure compliance with applicable healthcare regulations, contractual requirements, and company policies.
- Identify opportunities for process improvement, automation, and operational efficiencies.
- Support claims fraud detection, investigation, prevention, and recovery activities.
- Work closely with Operations Manager to assist in managing remote consultants.
- Allocate work and resources to ensure operational objectives are achieved.
- Adjudicate staff claims and claims requiring management approval or special handling.
- Review and negotiate provider reimbursement arrangements and discount opportunities where applicable.
- Assist with provider and facility relationship management initiatives.
- Lead and participate in strategic projects, technology enhancements, and business process improvement initiatives.
- Support audit, compliance, risk management, and governance activities.
- Undertake other duties as assigned to support the operational objectives of CG Coralisle Medical Insurance.
- Communicate departmental goals, expectations, and performance standards, and manage employee performance through regular coaching, feedback, performance appraisals, development planning, attendance management, and corrective action, as required.
- Identify training and development needs, coordinate onboarding activities, and provide leadership, coaching, mentoring, and development opportunities for claims employees.
- Partner with Senior Managers to support workforce planning, recruitment, retention, onboarding, employee relations, and staffing strategies necessary to meet operational requirements.
THE PERSON |
To be the ideal candidate you must have:
- Minimum of 10 years’ medical claims experience, including local and international claims adjudication.
- Demonstrated experience managing high-volume medical claims operations.
- Extensive knowledge of medical, dental, vision, prescription drug, life, and disability benefits.
- Strong understanding of healthcare reimbursement methodologies, provider contracting, utilization management, and medical cost containment strategies.
- Strong knowledge and current proficiency in ICD-10, CPT, ADA, ODA coding systems and medical terminology.
- Knowledge of HIPAA and other healthcare privacy regulations is considered an asset.
- Experience participating in healthcare industry committees, Bermuda Health Council initiatives are highly desirable.
- Strong leadership, coaching, communication, analytical, organizational, decision-making, problem-solving, and strategic thinking skills.
- Ability to interpret complex medical documentation, work effectively under pressure and manage multiple priorities.
- Strong English and mathematics skills.
- Advanced proficiency in Microsoft Office applications and business systems.
THE BENEFITS |
We value our employees and offer a supportive and inclusive work environment. We provide opportunities for professional growth and development, competitive compensation, and a comprehensive benefits package.
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