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Co-operators

Health Claims Adjudicator

Toronto, ON, Canada

Pay: Expected salary range $43,550 - $72,583
Job type: Full-time
Apply by: Oct 30, 2026
Experience: You have 1 year of experience in group health and dental benefits field.
Posting language: English
Posted: Sep 30, 2026

Apply About employer

Applications open in a new tab.

Original job description

Company: CLIC

Department: Group Benefits

Employment Type: Regular Full-Time

Work Model: Hybrid (2 days in office)

Language: This role operates in English.

Additional Information: This/these role(s) is/are currently vacant

The Opportunity

We are a leading Canadian financial services co-operative committed to being a catalyst for a sustainable and resilient society and our team is essential to deliver on this strategy. That’s why we prioritize our people, to ensure we provide a strong culture and development opportunities which enables our team to thrive and to live our purpose. The best part is that you will work with people that care passionately about you, our clients and our communities.

Our Group Benefits team is a leader in our target markets through service excellence and innovative technology and products. Influenced by our co-operative values, our team of experts work collaboratively with clients to deliver solutions that meet their business needs.

The Health Claims Adjudicator reviews, adjudicates and processes group extended health and dental claims according to policy guidelines while also taking into consideration industry standards and applicable provincial legislation. Success is measured by accuracy of adjudication, clear and professional communication, meeting productivity targets, and recommending improvements to work processes.

How You Will Create Impact

Adjudicate health and dental claims in accordance with plan provisions, policies, and contractual requirements.
Review Cost Plus and Out‑of‑Country claims to make sure coverage rules and eligibility criteria are applied correctly.
Interpret plan provisions, policies, and contracts to support accurate benefit decisions and compliance with regulatory and organizational standards.
Coordinate tasks and effectively oversee designated workloads in multiple adjudication queues and shared email inboxes to facilitate prompt processing of claims.
Prioritize tasks effectively to meet established service level agreements, productivity targets, and quality expectations.
Communicate professionally and effectively with internal partners, providers, and members to clarify coverage, resolve issues, and explain adjudication outcomes.
Apply critical thinking and sound judgment to identify opportunities for process improvements and provide rationale for recommended enhancements.
Support departmental initiatives and projects that promote operational efficiencies and continuous improvement.

To Join Our Team

You have a degree in health science, insurance, business administration or related fields.
You have 1 year of experience in group health and dental benefits field.
GBA(Group Benefits Associate) and or ALHC(Associate, Life and Health Claims) designation would be considered an asset.
You are proficient in data entry with a demonstrated ability to maintain attention to detail and accuracy.
You have a strong written and verbal communication skills for professional interactions with clients and providers.
You possess critical thinking abilities and an inquisitive mindset to review and refine policy guidelines.

How You Will Succeed

You influence change and are committed to continuous improvement, in order to exceed client expectations.
You leverage critical thinking skills to identify problems and proactively propose solutions.
Your strong communication skills allow you to clearly convey messages.
You’re an effective team player who shares knowledge to support our peers.

What You Need To Know

You will be subject to a Background check as a condition of employment, in the event you are the successful candidate.

What’s in it for you?

Training and development opportunities to grow your career.
Flexible work options and paid time off to support your personal and family needs.
A holistic approach to your well-being, with physical and mental health programs and a supportive workplace culture.
Paid volunteer days to give back to your community.
In addition to our competitive salary and incentive programs, eligible employees also benefit from a comprehensive total rewards package including group retirement savings plans, pension and benefits (e.g., health and wellness, dental, disability and life coverage), mental health support and an employee assistance program.

Expected salary range $43,550 - $72,583

The salary amount for the successful candidate is determined by Co-operators in its discretion and will vary depending on several criteria including but not limited to: local market conditions, geography and relevant job-related factors such as knowledge, skills, qualification, experience and education.

Employees may also have the opportunity to participate in incentive programs and earn additional compensation tied to individual and/or business performance, or other business metrics.

Apply About employer

More about this job

Responsibilities

Adjudicate and process group health and dental claims, including Cost Plus and out-of-country claims, in accordance with plan provisions, contracts, policies, and applicable regulations. Manage assigned workloads and communications to meet service and quality targets, explain decisions to stakeholders, and contribute to process improvements and departmental initiatives.

Requirements

A degree in health science, insurance, business administration, or a related field and one year of experience in group health and dental benefits are required. Candidates should demonstrate accurate data entry, strong written and verbal communication, critical thinking, and an inquisitive approach; GBA or ALHC designations are an asset.

Skills

Health And Dental Claims Adjudication
Group Benefits
Policy Interpretation
Contract Interpretation
Claims Processing
Cost Plus Claims Review
Out-Of-Country Claims Review
Data Entry
Attention To Detail
Accuracy
Critical Thinking
Sound Judgment
Written Communication
Verbal Communication
Workload Prioritization
Process Improvement

Benefits

Training And Development Opportunities
Flexible Work Options
Paid Time Off
Physical And Mental Health Programs
Supportive Workplace Culture
Paid Volunteer Days
Pension
Health And Wellness Coverage
Dental Coverage
Disability Coverage
Life Coverage
Mental Health Support
Employee Assistance Program
Incentive Programs

Visa sponsorship

Not detected in the job text

Keywords

Group Benefits
Health Claims
Dental Claims
Claims Adjudication
Claims Processing
Cost Plus Claims
Out-Of-Country Claims
Plan Provisions
Policy Guidelines
Contractual Requirements
Provincial Legislation
Regulatory Compliance
Eligibility Criteria
Service Level Agreements
Productivity Targets
Quality Expectations
Data Entry
Critical Thinking
Process Improvement
Continuous Improvement
GBA
ALHC
Health Science
Insurance
Business Administration

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