Health Claims Specialist

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• Full TimePermanent position
• Hybrid role based in our Dublin City Centre or Cork Office (South Mall)
• Closing date is 12/05/2026

Irish Life Health is part of the Irish Life Group of companies. The Claims Operations function is looking for a motivated and driven Health Claim Specialist to join their team. The successful applicant will be part of a driven team who ensure high quality standards are maintained at all times, working to achieve service and quality standards and striving towards the perfect customer experience

Fitness & Probity

This role is a 'controlled function' as defined by the Central Bank Reform Act 2010 Regulations 2011. Any appointment will be conditional on the company being satisfied that the appointee meets the requirements as set out in the Fitness and Probity standards issued by the Central Bank. This requires the company to complete prescribed due diligence to assess the appointee's fitness and probity. Further details on this due diligence process are available from HR.

What we offer

We have embraced a hybrid working model for most of our positions, which means that you can enjoy a balanced approach of working from home for part of the week and working from the office for the remainder of the week.

We offer a comprehensive benefits package including competitive salaries and bonuses, robust Learning and Development support, excellent Defined Contribution pension and comprehensive Wellbeing initiatives and support.

At Irish Life, our purpose is to help people build better futures. Our company values shape everything we do and underpin our vision of being the driving force behind Ireland's financial, physical, and mental well being.

We believe in doing the right thing-acting with integrity and making fair, responsible decisions. We aim high, setting ambitious goals and find better ways to innovate and improve. Our customers are at the heart of everything we do and we are dedicated to understanding their needs and exceeding their expectations. Achieving this is only possible when we work best together-in a supportive, collaborative environment where every idea and contribution is valued.

Role Purpose

The Health Claims Specialist plays a critical role in the accurate assessment and payment of both hospital and member claims, ensuring compliance with governance, regulatory and quality assurance standards. The role is responsible for managing pre approvals (local and overseas), team mailboxes, performing governance audits and control reporting. By analysing trends, audit outcomes and claims data, the Health Claims Specialist drives continuous improvement, helping to streamline processes, reduce waste work and deliver a consistently high quality experience for our customers and provider partners. APA PMI qualification preferred.

Key Responsibilities

• Complete governance audits for processed hospital and member claims in line with the Quality Assurance Strategy.
• Management and oversight of daily control report generation and review to ensure the effectiveness of the claim's governance framework.
• Process all local and overseas pre approval requests in accordance with agreed procedures.
• Act as the first line of defence in identifying potential inappropriate billing, fraud, waste and abuse within hospital and member claims process.
• Actively manage all team mailboxes, ensuring responses and actions are taken within agreed KPIs.
• Identify and report ineffective or inefficient controls or claims processes, and provide recommendations for corrective actions to Senior Management.
• Identify trends and patterns from audits and claims activity, and support the implementation of appropriate remedial and preventive actions.
• Review and maintain documentation (policies, procedures, guidelines) to ensure it is up to date, accurate and relevant.
• Identify waste work and opportunities to improve and streamline the claims process, supporting continuous improvement initiatives.
• Assist in the production and delivery of training materials for our TPA partners to ensure that the agreed processes and procedures are rolled out effectively in a controlled manner.
• Provide excellent customer service to members and providers, maintaining a strong customer focus in all interactions.

The Person

• Holds an APA PMI qualification (or higher).
• 1-5 years' experience in health insurance claims assessment.
• Customer focused, motivated to make a difference, and keen to contribute to the achievement of business objectives.

Skills and Experience

• Proven experience in health insurance with a good knowledge of claims processes, assessment rules, and policy terms and conditions.
• Claims audit experience and a good understanding of governance principles (desirable).
• Excellent knowledge of health insurance plans and relevant legislation.
• Strong IT skills with the ability to work confidently across multiple systems, including advanced proficiency in Microsoft Excel (e.g. formulas, data analysis, reporting).
• Excellent communication and interpersonal skills.
• Self starter, able to work on own initiative.
• Proven ability to manage a demanding workload and prioritise effectively.
• Strong team player with a commitment to supporting colleagues and achieving common goals.
• Good systems knowledge and proficient in Microsoft Office.

Equal Opportunity Statement

Irish Life Health supports Equal Opportunity and is regulated by the Central Bank of Ireland.