Are you looking for an opportunity to be a solid contributor to the company's success by applying your tremendous team collaboration, process improvement, time management skills? This job requires that you enjoy investigating and analyzing medical records. The successful candidate for this position is able to apply critical analysis by thinking outside of the black and white and then give written summaries of their reasoning on decisions. We are looking for a candidate who is seeking a position offering the opportunity to grow their established Long Term Care Eligibility experience.
** Job Summary**
This position is responsible for the review of policy benefit eligibility in accordance with policy, company, state, and federal guidelines. This position is for Long-Term Care Insurance Plans.
Supervisory Responsibilities:
This job has no supervisory responsibilities.
** Duties/Responsibilities:**
Responsible for accurate/timely daily review of Long-Term Care benefit eligibility in accordance with policy provisions to determine appropriate eligibility approval or denial.
Responsible for accurate/timely determination of benefits and additional benefits applicable under policy provisions such as Wavier of Premium, Inflation Protection Options, Guaranteed Purchase Options, and other applicable rider/policy benefits.
Responsible for interpreting policy provisions to accurately determine claim benefits in accordance with policy benefits
Responsible for timely request of claimant’s assessment and follow-up request of any/all required additional information, i.e., medical records, appropriate forms, statements, and certificates needed for proper eligibility determination
Ensure systems and documents are updated on all follow-ups and status throughout the eligibility process
Review and work other applicable reports and documents pertaining to eligibility determination
Responsible for sending correspondence timely to claimant about benefit eligibility determination
Respond appropriately and professionally to all oral and written external and/or internal correspondences received from stakeholders regarding benefits, eligibility, claim payments, denials and/or explanation of benefits
Ensure appropriate systems are updated timely and clearly regarding eligibility rationale on how determinations were made in accordance with policy provisions and documents received
Work with management, medical director, and client on review of complex eligibility cases
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
Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files
Other duties that are assigned
Required Skills/Abilities:
To perform this job successfully, the individual must be able to perform each essential duty effectively. The individual must possess advance product knowledge, comprehensive understanding of insurance terminology and definitions, core knowledge of company and department processes and procedures related to the ability to complete job responsibilities /duties in a proficient and professional manner.
Claim Eligibility Specialist must have knowledge of medical terminology, ICD-9/10 and CPT/HCPC/CDT coding; Familiarity with different medical claim forms, i.e., HCFA-1500 and UB04 forms; working knowledge of Insurance Industry and/or Healthcare.
Ability to read and interpret documents such as policies and operating and procedural manuals. Ability to write routine correspondence. Ability to speak effectively to customers, clients, or employees of the organization.
Customer Service; Work Standards; Decision-Making; Communication (oral and written); Organizational Skills and Motivation
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
Education and Experience:
Two years certificate/degree from college or technical school; or 4-7 years related experience and/or training; or equivalent combination of education and experience.