Claims Manager - LSW or RN

Claims Manager 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 Service Level Agreements (SLAs).
• 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 to others who need it, based on HIPAA and legal documents regarding release.
• Perform work accurately and demonstrate ability to prioritize workload.
• Participate in team meetings and assist colleagues with their work loads when appropriate.
• Uphold the principles of compliance as outlined in the Code of Conduct, Employee Handbook and related policies and procedures. Supports and participates in the mandatory Corporate Compliance Program training initiative on an annual or more frequent basis, as required.
• Meet established quality and production expectations as established and communicated by the department.
• Other duties as assigned.

Qualifications

Required:

• Bachelor’s degree in a relevant field (e.g., healthcare, social work, etc.)
• Minimum of 5 years of experience in long-term care insurance claims processing, preferably in a managed care environment.
• Strong knowledge of long-term care insurance policies, including understanding of chronic illness riders and critical illness coverage.
• Experience with medical coding and billing systems.
• Excellent communication and interpersonal skills.
• Proficiency in Microsoft Office Suite, particularly Excel and Word.

Preferred:

• Knowledge of Medicaid and Medicare regulations.
• Experience with electronic health records (EHRs).
• Experience with data analysis tools.