Senior Health Claims Adjudicator

About the role

We are seeking an experienced and detail‑oriented Senior Health Claims Adjudicator to join Guardian Life of the Caribbean Limited. The role involves assessing and adjudicating complex health claims, ensuring compliance with policy and regulatory requirements, and delivering fair, timely outcomes while supporting exceptional customer service.

Key responsibilities

• Coordinate the review and processing of complex local, regional and overseas health claims in line with established authorization limits.
• Assign complex claims to junior adjudicators and provide training and guidance.
• Authorize all claims and precertification requests that exceed the standard adjudicator limits.
• Liaise with the Medical Advisor and Technical Officer to determine overseas eligibility, pre‑existing conditions, medical necessity and verification of benefits.
• Manage overseas case eligibility, execute large or complex precertification requests, and complete verification of benefits for insureds seeking medical attention abroad.
• Handle client escalations promptly, make decisive decisions in time‑sensitive situations, and maintain a solution‑oriented approach.
• Assist in updating and maintaining claims‑processing procedures for health claims operations.

Required profile

• Strong analytical mindset with a commitment to excellence.
• Detail‑oriented and able to work under pressure.
• Experience in health claims adjudication, including complex and overseas cases.
• Ability to train and mentor junior team members.
• Effective communication and problem‑solving skills.

Required skills

• Knowledge of health insurance claim processes and regulatory requirements.
• Familiarity with medical terminology and pre‑certification procedures.