Claims Manager

Location

United States

Posted

3 days ago

Salary

$60K / year

Seniority

Lead

No structured requirement data.

Job Description

Claims Manager

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 target is at $60,000 depending on experience and qualifications.

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