Claims Manager - LSW or RN

About the role

We are a leading provider of business process outsourcing for the insurance industry, managing over 1.3 million long-term care policies for the nation's largest insurers. We also provide clients with unique risk management insight built upon our proprietary long-term care databases. The Claims Manager position is responsible for evaluating and rendering eligibility decisions on home and facility-based Long Term Care claims (standalone and hybrid), chronic illness riders, and/or critical illness within client contract and policy parameters, while providing quality customer service to our policyholders, their representatives, and providers. A Claims Manager will be required to review and certify chronic illness claims.

Responsibilities

• Review internal databases, client guidelines, and policy contract language to evaluate routine home and facility-based claims in accordance with department processes and standards.
• Communicate clearly and routinely with claimants, representatives, third parties, physicians, and healthcare providers via written letters and phone calls as required by agreed-upon SLAs. Additionally, effectively communicate with team members and leadership on cases as needed.
• Query service providers to obtain licensure information, proof of loss, and dates of service.
• Verify that provider and/or care is appropriate based on the claimant’s diagnosis and is in accordance with contract language and government regulations regarding healthcare providers.
• Maintain clear and concise documentation of all claim activity within the required databases.
• Create plans of care and complete Chronic Illness Certification as appropriate.
• Provide prompt, courteous, and excellent customer service to internal and external customers.
• Demonstrate effective communication skills, level of attentiveness, and use of appropriate lines of authority.
• Promptly share accurate and complete information with others who need it, based on HIPAA and legal documents regarding release.
• Perform work accurately and demonstrate the ability to prioritize workload.
• Participate in team meetings and assist colleagues with their workloads when appropriate.
• Uphold the principles of compliance as outlined in the Code of Conduct, Employee Handbook, and related policies and procedures.
• Support and participate in the mandatory Corporate Compliance Program training initiative on an annual or more frequent basis, as required.
• Meet established quality and production expectations as communicated by the department.
• Work independently with minimal direction.
• Other duties as assigned.