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