[Hiring] Claims Manager I @illumifin

Role Description

The Claims Manager position is responsible for evaluation 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 policy holders, their representatives and providers.

• 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.
• 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 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 established and communicated by the department.
• Work independently with minimal direction.
• Other duties as assigned.

Qualifications

• Current and Unrestricted Registered Nurse (RN) or Social Work license.
• Four-year college degree or equivalent formal training program.
• Two years’ experience in medical, insurance or risk management setting.
• One-year work experience in claim processing.
• Intermediate level experience with Microsoft Office products.
• Excellent verbal and written communication.

Requirements

• Experience working in a geriatric healthcare environment (preferred).
• Knowledge of health, long-term care of disability insurance (preferred).

Benefits

• The annual compensation range starts at $60,000 but can increase depending on experience and qualifications.