Health Claims Specialist

About the Role

This full-time, permanent position is based on a hybrid working model, primarily located at our Dublin City Centre and Cork Offices. As a Health Claims Specialist, you will be instrumental in accurately assessing and processing both hospital and member health claims, ensuring full compliance with governance, regulatory, and quality assurance standards.

Key Responsibilities

• Conduct governance audits on processed hospital and member claims following the Quality Assurance Strategy.
• Oversee and manage daily control reporting related to member and hospital claims to verify the effectiveness of the claim governance framework.
• Process local and overseas pre-approval requests according to approved procedures.
• Serve as the first line of defense to identify potential inappropriate billing, fraud, waste, and abuse in claims processing.
• Manage all team mailboxes, ensuring timely responses and actions within established KPIs.
• Detect and communicate ineffective or inefficient controls or claims procedures, proposing corrective solutions to Senior Management.
• Analyse trends and patterns from audit results and claims data, supporting corrective and preventive measures' implementation.
• Maintain and update relevant policies, procedures, and guidelines to ensure accuracy and relevance.
• Identify redundant work and opportunities to optimize and streamline claims processes, assisting continuous improvement initiatives.
• Assist in developing and delivering training materials for third-party administrator partners to ensure controlled process implementation.
• Provide excellent customer service, focusing on member and provider satisfaction in all interactions.

Candidate Profile

• Possession of an APA PMI qualification or higher is preferred.
• Between 1 to 5 years of experience in assessing health insurance claims.
• Customer-oriented, motivated to make a positive impact, and eager to contribute towards achieving organizational goals.

About Irish Life Health

Irish Life Health is part of one of Ireland's largest financial entities, serving over 1.5 million customers and providing health insurance to more than 500,000 people nationwide. The company focuses on enabling healthier lives through accessible healthcare solutions such as 24/7 Digital Doctor access, counselling through the Healthy Minds program, and specialized physiotherapy services for acute back or neck pain.

Additional Information

This role is classified as a ‘controlled function’ under the Central Bank Reform Act 2010 Regulations 2011, requiring the successful applicant to meet the Fitness and Probity requirements. The company will perform due diligence to assess suitability.

Irish Life offers a comprehensive benefits package including competitive salaries, bonuses, strong learning and development support, an excellent Defined Contribution pension plan, and an extensive range of wellbeing initiatives.

The company promotes equal opportunity, inclusion, and a supportive workplace culture where diversity and employee value are prioritized. Accommodations are available during the recruitment process upon request.

Please note the company reserves the right to shortlist candidates and will collaborate directly with selected recruitment agencies; unsolicited applications from agencies will not be acknowledged.