Claims Adjustments Senior Representative

Band 2  |  Global Service Centre

ROLE SUMMARY
As a Claims Adjustment Senior Representative, you will support clients across the world by delivering accurate, timely and high-quality adjustment and claims processing. Reporting to the Claims Adjustment Supervisor, you will manage standard and higher-complexity adjustments, including failed payments and medical, dental and vision claim activity received from providers, partners, clients and members. You will act as a reliable escalation point, support workflow and quality management, guide colleagues, and help strengthen operational consistency, compliance and customer outcomes.

Claims Adjustment Processing & Complex Case Handling

·        Process and adjudicate medical, dental and vision claim adjustments in line with policy terms, benefit plans, SOPs, business rules and defined authority limits.

·        Handle failed payments, exceptions, unclear scenarios and non-routine adjustment cases independently, escalating where authority or guidance is required.

·        Review, investigate and resolve aged, escalated, priority or high-cost cases, ensuring relevant stakeholders are informed.

·        Maintain accurate, complete and audit-ready system updates, calculations, documentation and case notes.

·        Monitor turnaround times and complete work within agreed service levels, highlighting risks or delays promptly.

Customer & Stakeholder Support

·        Respond within agreed time commitments to enquiries relating to plan design, eligibility, claim or adjustment status, and take the required action to support resolution.

·        Work effectively with internal and external customers, providers and partners to investigate issues and achieve clear, accurate outcomes.

·        Consider the downstream impact of adjustment decisions and support smooth end-to-end claims and payment processing.

Quality, Accuracy, Risk & Compliance

·        Complete peer reviews and quality checks as assigned by the supervisor or team lead.

·        Identify and escalate recurring errors, processing risks, potential overpayments, procedural gaps or customer-impacting issues.

·        Adhere to regulatory, audit, data-protection and internal control requirements, maintaining confidentiality at all times.

·        Model right-first-time processing and consistently meet individual and team productivity and quality standards.

Workflow, Data & Reporting Support

·        Support the monitoring of adjustment and claims work queues, prioritising critical, high-cost, aged and service-sensitive cases.

·        Review operational data to identify trends, discrepancies, recurring adjustment drivers or potential root causes, and highlight insights to leaders.

·        Ensure accurate case categorisation and data entry to support reliable reporting, dashboards and operational summaries.

Process Improvement & Knowledge Sharing

·        Interpret SOPs and guidance in complex or ambiguous situations, seeking clarification where required and helping colleagues apply them consistently.

·        Provide practical day-to-day support, informal coaching and knowledge transfer to colleagues, including new hires and less-experienced analysts.

·        Identify process inefficiencies and recommend improvements that strengthen accuracy, controls, turnaround time and customer experience.

·        Contribute to the maintenance of guides, templates, FAQs and checklists used within Claims Adjustment.

Cross-Team & Regional Collaboration

·        Collaborate with Claims, Payment, Eligibility, Customer Service, Finance, Quality, Product, Compliance and Technology teams to resolve operational issues.

·        Work across European and Middle East operations, and with other regions where required, to support consistent service delivery and knowledge sharing.

·        Actively support colleagues and flex across priorities to help achieve team goals and meet business needs.

·        Complete other reasonable duties appropriate to the role.

·        1-2+ years of experience in claims, adjustments, payment processing or a comparable back-office operations environment.

·        Working knowledge of claims or adjustment workflows, policy terms, benefit plans, SOPs and system navigation.

·        Demonstrated ability to manage complex, escalated or exception cases independently and exercise sound judgement within defined authority.

·        Excellent attention to detail, numerical accuracy and ability to organise and prioritise multiple workloads against deadlines.

·        Good analytical and problem-solving skills, with the ability to investigate issues, identify patterns and support root-cause understanding.

·        Strong written and verbal communication skills, with the confidence to work with internal and external stakeholders.

·        Ability to support colleagues through practical guidance, knowledge sharing and constructive feedback.

·        Customer-focused, proactive and adaptable, with awareness of how back-office decisions affect service and member outcomes.

·        Proficient in Microsoft Office applications and confident learning multiple operational systems.

·        Fluent in English; additional languages are beneficial. Relevant English and numeracy qualifications are preferred.

Claims & Adjustment Expertise

Applies policy, benefit, payment and procedural knowledge to deliver accurate adjustment outcomes.

Problem Solving & Judgement

Investigates exceptions, identifies root causes and makes sound decisions within authority.

Quality & Compliance

Prioritises accuracy, audit readiness, data protection, controls and error reduction.

Customer Focus

Understands customer impact and supports timely, clear and appropriate resolution.

Collaboration & Coaching

Works effectively across teams, supports peers and contributes to knowledge transfer.

Continuous Improvement

Identifies trends and recommends practical improvements to claims and adjustment processes.

Communication

Communicates clearly, professionally and supportively with colleagues, leaders and stakeholders.

Time & Priority Management

Manages complex workloads, service levels and competing priorities effectively.

Systems & Data

Uses operational systems confidently and maintains accurate information for reporting and control.