Claims Examiner I
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Job Description
Claims Examiner I processing ongoing long-term care insurance claims for Davies North America. Reviewing documentation and ensuring claims eligibility in a remote setting.
Responsibilities:
- Process ongoing long-term care insurance claims for either facility or non-facility processing only
- Review long-term care invoices, Monthly Verification Forms, caregiver logs and/or Statement of Care forms, and all other claims documentation received to determine continued eligibility and proper payment amount
- Determine whether documentation substantiates that the policyholder continues to meet the level of care and services contained in the policy and approved by the Claim Manager
- Recognize and refer possible plan of care changes to Claim Management Department based on established Department business rules
- Accurately document policyholder accounts and correspondence in accordance with established Department processes and procedures
- Identify and refer possible fraud cases for further investigation
- Process and document all required diary entries in the CAPS system
- Maintain compliance with all applicable laws and regulations
- Meet or exceed all regulatory requirements for processing claims submitted for payments including prompt-pay regulations
- Process payments in accordance with federal and state laws and Medicare/Medicaid regulations that affect the management and administration of claims
- Handle confidential information abiding by HIPAA privacy laws
- Meet or exceed all established minimum expectations/metrics and goals for the position
- Meet or exceed standards for Productivity and Quality as established for the role
- Practice excellent oral and written skills to communicate with policyholders or their representatives, and providers by telephone and in writing, as well as with internal co-workers
- Maintain adherence to all Claim Payment Department processes and procedures
- Support company values of *We are Dynamic, We are Innovative, We are Connected, and We Succeed Together*.
- Perform other duties as assigned.
Requirements:
- High school diploma or combination of education and experience
- Minimum of two years’ experience processing and auditing claims
- Experience working with medical records and reviewing claims
- Knowledge of long-term care insurance highly preferred
- Knowledge of claims processing and regulatory requirements affecting claims processing
- Possess the ability to perform responsibilities with a sense of urgency demonstrating excellent organizational, attention to detail and customer service skills
- Ability to work in a team environment with a positive attitude
- Possess excellent oral/written communication, interpersonal, analytical, and problem-solving skills
- Knowledge and ability to utilize existing software products including, but not limited to, MS Office products; ability to learn new systems and upgrades in technology utilized
- Ability to learn and relay knowledge of products offered by the Company
- Ability to read and interpret complex policy contract language and correspondence including knowledge of Medicare forms and medical terminology
Benefits:
- Medical, dental, and vision plans to ensure your health and that of your family.
- A 401k plan with employer matching to help you build a secure financial future.
- Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
- Paid holidays.
- Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.
- Diversity and inclusion initiatives that embrace a wide range of perspectives and experiences.
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