Wellcove

• Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files. • Review requests involving Power of Attorney, Guardianship and Authorizations to Release Information. • Assist the Claims team in requesting medical documentation to adequately adjudicate long-term care eligibility. • Reviewing the documents received to determine if complete and accurate. • Assist Claims Management with assigning work activities to associates within our workflow. • Respond professionally and timely to customer inquiries. • Ensure service calls are made in a timely, efficient and knowledgeable manner. • Follow up on any outstanding documentation with additional correspondence, reviewing fax failures, and reviewing any returned mail. • Contact providers and customers to obtain accurate contact information. • Maintain current knowledge of federal, state, and insurance regulations and requirements. • Maintain working knowledge of all company and services pertaining to business segment. • Maintain working knowledge and proficiency in company claims and administrative software systems as well as Microsoft applications. • Maintain client and company quality and production standards. • Maintain knowledge of applicable company policies and procedures. • Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information. • Other duties may be assigned

• Review all policy administration and claim level transactions against the standard operating procedures. • Maintain the review of all Daily and Monthly billing suspense items. • Responsible for reviewing benefit eligibility determinations to ensure that the claim recommendations meet the contractual obligations of the policy. • Assign and document all mechanical and financial errors as discovered. • Maintains a strong working knowledge base of all Long-Term care products and services. • Maintain production and quality standards established in the department. • Participate and support policy review decisions in the appeal process. • Monthly reporting to all engagement managers and supervisory staff on the quality results of their department and staff • Participate in client level meetings. Create action plans as agreed upon with the client and meet all timelines and deliverables. • Complying with company regulations regarding HIPAA, confidentiality, and private health information. • Other duties may be assigned. • Ability and Flexibility to work overtime as required.

• Ability to review and analyze complex medical documentation with a high degree of accuracy to prevent errors in claims processing. • Evaluate claims against established guidelines, contracts, and regulatory requirements. • Conduct detailed research on complex claims, pre-existing conditions, and other intricate scenarios. • Analyze medical records, policy documents, and other relevant information to make informed claim decisions. • Demonstrate proficiency in healthcare coding systems (e.g., CPT, ICD-10, HCPCS, Revenue codes, medical terminologies, Human Anatomy, Inpatient Vs. Outpatient claims) to accurately assess claims. • Apply knowledge of healthcare benefits and payment policies. • Provide clear and concise explanations of claim decisions to relevant parties. • Identify trends and patterns in complex claims to contribute to process improvements. • Candidate should be able to correctly calculate claim amounts for the customers. • Complying with company regulations regarding HIPAA, confidentiality, and private health information.

• Manage and handle all Outbound calls and adjudicate claims. • Adjudicating HP/AD claims. • Handling all Outbound calls. • Should be able to prioritize work and adjudicate claims as per turnaround time. • Job involves working independently on researching, reviewing, summarizing, and recommending a course of action on claims where an appeal or a grievance has been filed for a denied / under payment. • To ensure claims are adjudicated as per the client/company guidelines. Provide continual evaluation of processes and procedures. • To respond to and resolves claims received via emails. • Candidate should be able to correctly calculate claim amounts for the customers. • Complying with company regulations regarding HIPAA, confidentiality, and private health information.

• A process leader leads, monitors, and administrates a group of employees to achieve goals. • Provides daily direction and communication to employees so that the business deliverables are intact, efficient, and knowledgeable manner. • Monitoring operational activities of claim examiners to ensure claims are processed accurately and timely. • Provide technical support, expert advice, and coaching assistance to team members and clients. • Identify new opportunities to improve operational effectiveness and customer satisfaction and make recommendations for improvements. • Identify skill gaps and ensure training is provided to further develop staff. • Should manage team conflict and any people related issue. • Handle complaints, DOI, Appeal etc. Adhere to process reporting, able to draft process documents, including SOP, Update tracker, issue logs etc. • Ability to do quality audit for team process. • Ability to speak to client on process related issues and able to handle the calls with client.

• Perform detailed clinical reviews of LTC claim files to determine eligibility in accordance with policy provisions and regulatory requirements. • Assess Activities of Daily Living (ADLs), cognitive impairment, diagnoses, comorbidities, and level of care needs. • Review medical records, Minimum Data Set (MDS) assessments, facility documentation, home health records, daily visit notes, and supporting claim forms. • Determine whether the insured meets the policy definition of Chronically Ill. • Prepare and document Chronically Ill Certifications (CICs) and individualized Plans of Care (POCs) for initial approvals and recertifications. • Clearly document clinical rationale to support benefit determinations. • Collaborate with Claims, Eligibility, and Customer Service teams to obtain additional documentation when necessary. • Maintain knowledge of LTC policy language, benefit triggers, and regulatory requirements.

• Collect, interpret, and validate data from multiple sources, ensuring accuracy and consistency • Create, maintain, and manage advanced reporting, dashboards, and BI solutions • Perform and document data analysis, validation, and mapping/design to improve reporting quality • Review and enhance existing systems, and collaborate with teams to integrate new reporting tools • Conduct market or operational research to identify trends and support strategic decisions • Develop and implement data collection systems to optimize statistical efficiency and data quality • Prepare executive-level reports summarizing trends, patterns, and forecasts using relevant data • Work with management and stakeholders to gather requirements, provide updates, and build relationships • Maintain compliance with data handling policies and ensure confidentiality of sensitive information • Identify process improvements to streamline reporting workflows and reduce errors • Analyze EVV data to identify missed visits, documentation inconsistencies, and compliance risks • Monitor visit verification trends and recommend corrective actions • Partner with operations to strengthen oversight and ensure adherence to state and federal EVV requirements • Perform monthly reporting • Other projects as defined

• Making outbound calls to complete assessment scheduling • Answering inbound phone calls for messages left from outbound calls • Each day, handling a total of at least 50 phone calls (a combination of inbound and outbound calls) • Receiving a score of 85% or greater on QA scores (2 completed each month) • Not exceeding 30-minute meal and break times daily • Averaging 25% or less on After Call Work Time • Team collaboration • Other projects as defined

• Serve as a point of contact for clients utilizing Wellcove’s EVV and Facility platforms, addressing inquiries and resolving issues promptly. • Assist claimants, caregivers, home care agencies, and facilities in ongoing inquiries regarding the EVV and Facility platforms. • Provide training and guidance to clients on the use of EVV and Facility platforms, tools, and processes. • Gather required information from clients accurately record data in Wellcove’s platforms/systems. • Maintain organized documentation for all client interactions, training sessions, and compliance activities. • Provide outstanding customer service via phone and email, displaying professionalism, empathy, a sense of urgency, and a genuine willingness to help. • Independently process caller requests accurately and promptly in Wellcove’s proprietary system and escalate as appropriate. • Comply with customer support objectives and performance standards. • Effective use of process resources to gain knowledge base and ensure the delivery of accurate information and error-free processing of requests. • Other duties as assigned.

• Provides daily directions and communication to employees so that the customer service calls are answered in a timely, efficient and knowledgeable manner. • Provide continual evaluation of processes and procedures. • Responsible for suggesting methods to improve area operations, efficiency and service to both internal and external customers. • Provide statistical and performance feedback and coaching on a regular basis to each team member. • Write and administer performance reviews for skill improvement. • Provide support for employees by providing appropriate coaching, counseling, direction and resolution. • Ensure employees have appropriate training and other resources to perform their job. • Respond to and resolve employee relations issues expressed by team members. • Create and maintain high quality work environment so team members are motivated to perform at their highest level. • Address disciplinary and/or performance problems according to company policy. • Prepare warnings and communicate effectively with employees on warnings and make effective/appropriate decisions relative to corrective action as required. • Assist manager with daily operation of call center to include development, analysis and implementation of staffing and training. • Work as a member/leader of special or on-going projects that are important to area/process improvement. • Share continual responsibility for deciding how to manage the employees ensuring calls are handled efficiently and effectively. • Establish work procedures and processes that support company and departmental standards, procedures and strategic directives. • Communicate with upper management regarding department or employee concerns. • Complying with company regulations regarding HIPAA, confidentiality, and private health information.