Key Responsibilities and Required Skills for French Bilingual Claims Specialist

🎯 Role Definition

The French Bilingual Claims Specialist is responsible for end-to-end claims handling and adjudication while delivering high-quality bilingual customer service. This role requires accurate assessment of policy coverage, timely investigation and settlement, clear communication with claimants and providers in both French and English, and strict adherence to regulatory and company standards. The role supports operational goals for claim cycle time, cost containment, and customer experience for French-speaking markets or client groups.

This position typically works within a claims operations team, reporting to a Claims Supervisor or Manager, and collaborates with underwriting, medical review, legal and external vendors.

📈 Career Progression

Typical Career Path

Entry Point From:

Bilingual Customer Service Representative (French/English)
Claims Processor or Claims Administrator
Insurance Adjuster Trainee or Junior Claims Analyst

Advancement To:

Senior Claims Specialist / Senior Claims Adjuster
Claims Team Lead or Claims Supervisor
Claims Manager or Claims Operations Manager
Specialty Adjuster (Major Loss, Complex Liability, Medical)

Lateral Moves:

Underwriting Analyst (Bilingual)
Provider / Network Relations (Healthcare)
Risk Management or Compliance Analyst
Client Services / Account Management

Core Responsibilities

Primary Functions

Receive, triage and open new claims reported in French and English; accurately capture claimant, policy and incident details in the claims management system to ensure compliant and searchable claim records.
Conduct initial liability and coverage assessments by reviewing policy language, endorsements and exclusions, and determine whether claims meet policy terms and conditions for acceptance or denial.
Investigate claim circumstances by obtaining and analyzing statements, witness accounts, police reports, medical records and other supporting documentation to establish facts and identify potential exposures.
Communicate proactively with claimants, insureds, health care providers, vendors and attorneys in fluent French and English to manage expectations, gather information and explain claim decisions and next steps.
Adjudicate claims end-to-end—calculate reserves, verify benefits, validate invoices, process payments and issue settlements—while maintaining an auditable trail and strict data accuracy.
Negotiate settlements with claimants, claimants’ counsel and third-party providers, applying best-practice negotiation techniques to reach fair, cost-effective outcomes that minimize litigation exposure.
Escalate complex, high-value or legally sensitive claims to senior staff or legal counsel with a clear, documented summary of facts, exposures and recommended actions.
Manage medical and provider-related claims by coordinating medical bill reviews, utilization reviews and peer-to-peer discussions with clinical staff or third-party medical reviewers as required.
Coordinate and oversee external vendor relationships, including appraisers, independent adjusters, investigators and repair shops, ensuring timely deliverables and cost control.
Maintain and adjust claim reserves and financial estimates in accordance with company reserving guidelines and loss development expectations, updating reserves as new information emerges.
Ensure all claim handling activities comply with local, provincial/state and federal regulations (for example, privacy laws such as GDPR, HIPAA or PIPEDA where applicable), internal policies and industry best practices.
Prepare clear, concise and professional claim file documentation, letters and correspondence in both French and English for internal and external stakeholders, ensuring high-quality written communications.
Handle complex or escalated customer service interactions with empathy and de-escalation skills, aiming to resolve disputes at first contact and escalating when appropriate.
Review and adjudicate third-party liability and subrogation opportunities; pursue recovery actions against responsible parties while documenting potential recoverable amounts.
Track and meet KPI targets including claim cycle time, closure rate, accuracy, customer satisfaction (CSAT/NPS for bilingual interactions) and cost per claim metrics.
Use and maintain proficiency with claims management platforms (e.g., Guidewire, Duck Creek, ClaimCenter), CRM systems (Salesforce), and standard office tools to ensure efficient, auditable workflows.
Participate in claim file reviews, audits and quality assurance programs to ensure compliance with service standards and to identify opportunities for process improvement.
Train and mentor junior claims staff or new bilingual hires by sharing best practices, adjudication techniques and system workflows to improve team capability and performance.
Assist in complex medical, disability or indemnity claims by reviewing medical documentation, evaluating functional limitations and collaborating with clinical resources to determine benefit entitlement.
Support catastrophe (CAT) response efforts as needed, processing high-volume, time-sensitive claims with triage methods, temporary workarounds and cross-functional coordination.
Identify and recommend process improvements and automation opportunities (templates, macros, decision guides) to increase bilingual claims throughput and reduce manual rework.
Maintain current knowledge of product coverage changes, industry trends, legal developments and regulatory updates that impact claim adjudication and policyholder communications.
Prepare periodic reports and summaries for leadership on claims trends, emerging risks within French-speaking populations, and recommended mitigation or training actions.
Coordinate return-to-work, vocational rehabilitation or case management referrals for disability claims where applicable to facilitate claimant recovery and cost management.

Secondary Functions

Support ad-hoc data requests and exploratory data analysis.
Contribute to the organization's data strategy and roadmap.
Collaborate with business units to translate data needs into engineering requirements.
Participate in sprint planning and agile ceremonies within the data engineering team.
Assist in bilingual marketing, communications or outreach initiatives to French-speaking clients and brokers to improve claim awareness and satisfaction.
Participate in cross-functional projects (IT, compliance, actuarial) to pilot system upgrades, testing and rollouts for claims tools in French language environments.
Help maintain bilingual knowledge base articles, templates and FAQ content to improve service consistency for French-speaking claimants.
Provide input into underwriting and product teams on emerging claim trends that affect coverage or pricing for French-speaking segments.

Required Skills & Competencies

Hard Skills (Technical)

Fluent bilingual proficiency: professional verbal and written fluency in French and English; ability to manage complex claim conversations and articulate legal/coverage rationale in both languages.
Claims adjudication expertise: experience adjudicating auto, property, liability, health, life or disability claims from intake through settlement.
Policy interpretation: ability to read and interpret insurance policies, endorsements and exclusions to determine coverage and claim liability.
Claims systems proficiency: hands-on experience with industry-standard claims management systems (e.g., Guidewire, Duck Creek, ClaimCenter) and the ability to document and update files accurately.
Medical terminology and documentation review for health/disability claims, including reading clinical notes, diagnostic reports and billing codes.
Reserve setting and financial analysis: competency setting appropriate reserves, calculating payments and understanding claims financial impacts.
Regulatory and compliance knowledge: familiarity with relevant privacy and insurance regulations (GDPR, HIPAA, PIPEDA, provincial/state insurance acts) and adherence to reporting timelines.
Microsoft Office advanced skills: especially Excel (pivot tables, VLOOKUP), Word and Outlook for reporting and correspondence.
Basic data literacy: ability to extract and interpret claims metrics, support KPI reporting and work with BI tools or CSV exports.
CRM and vendor management tools: experience using Salesforce or vendor portals to track communications and external engagements.
E-discovery and document management: skill in organizing, redacting and producing claim documents for legal or audit purposes.
CAT and high-volume claims handling: experience following surge procedures during weather events or mass-loss incidents.

Soft Skills

Exceptional oral and written communication in French and English; able to explain complex coverage decisions clearly and empathetically.
Strong analytical and critical thinking skills to investigate facts, identify inconsistencies and make defensible claim decisions.
High attention to detail and accuracy when documenting files, calculating reserves and processing payments.
Customer service orientation with proven ability to de-escalate difficult conversations and preserve customer relationships.
Time management and prioritization skills to handle competing caseloads and meet SLA deadlines.
Negotiation and settlement skills with a focus on fair outcomes and cost containment.
Cultural sensitivity and respect for diverse backgrounds—especially when working with francophone clients in different regions.
Team collaboration and ability to work cross-functionally with underwriting, legal, medical and IT teams.
Adaptability and resilience in fast-paced or high-stress claim surge situations.
Continuous improvement mindset and openness to coaching, feedback and process change.

Education & Experience

Educational Background

Minimum Education:

High school diploma or equivalent with demonstrated bilingual proficiency in French and English.

Preferred Education:

Bachelor’s degree in Business Administration, Risk Management, Insurance, Healthcare Administration, Finance, Law, or related field.
Industry certifications (preferred): associate-level insurance designations (e.g., AIC, ANZIIF), Chartered Property Casualty Underwriter (CPCU) coursework, or claims-specific certifications.

Relevant Fields of Study:

Insurance, Risk Management or Actuarial Science
Business Administration or Finance
Healthcare Administration or Nursing (for medical/disability claims)
Law or Paralegal Studies
Languages, Translation or Communications (French focus)

Experience Requirements

Typical Experience Range:

2–5 years of direct claims experience handling adjudication, investigation, or customer-facing claim resolution; at least 1–2 years in a bilingual (French/English) client-facing role.

Preferred:

3–7+ years of claims experience, with demonstrated success managing complex or high-dollar claims in Property & Casualty, Health, Life or Disability lines.
Prior experience with Guidewire, Duck Creek, ClaimCenter or similar claims platforms.
Proven track record in negotiation, reserve management and bilingual communications with claimants and providers.