Performs quantitative and qualitative data analysis to accurately process reimbursement payments for Long Term Care needs.
Uses extensive claims knowledge in interpreting and analyzing pertinent facts to review claims data necessary for accurate financial claims management.
Responds to questions from incoming Insured or representatives’ phone calls and emails regarding requests for information needed for ongoing long-term claim administration.
Uses knowledge and empathy to identify, evaluate, and interpret client’s status and needs and provide proactive resolutions and recommendations to achieve desired results.
Communicates both verbally and in writing with Insureds and their representatives, field force, and service providers regarding insured’s eligibility for payment and decision-making reasoning.
Assist in determining provider eligibility as it relates to individual Insured’s plan of care by gathering information about Insured’s medical, function and cognitive status.
Collaborates with providers of care on behalf of Insured to obtain necessary supporting documentation needed to make decisions and process payments.
Captures and documents claim information accurately in the claim system; creates tasks as required; appropriately pulls work from assigned group planner.
Process exceptions as they relate to the contracts by interpreting state and contract variations.
Participate in team meetings, project and committee work as appropriate, including the development of process improvements.
Support training of new team members, as needed.
Analyzes eligibility for and approves or denies the payment of active long-term care claims.
Bachelor’s degree or equivalent in business, accounting, actuarial sciences, or mathematics .
Insurance claims background preferred.
Strong analytical and investigative skills.
Ability to draw logical inferences, problem-solve and apply judgement from explicit and implicit information.
Eager to learn new information and understand the end-to-end long term care claims process. Seeks out and is open to and obtaining constructive feedback.
Able to analyze complex information and asks thoughtful questions to understand the situation.
Able to pivot between different activities and alter approach based on changes in circumstances and/or information.
Exhibits empathy and strong client focus and customer service skills.
Enjoys the satisfaction from helping and building relationships with clients and colleagues and demonstrates strong support of team goals.
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