Claim Manager, Clinician

This is a fully remote position, open to applicants in Alabama.

📋 Description

• Assess the eligibility of LTC claims based on individual policy terms.

• Analyze LTC policy coverage using claims guidelines and policy language to determine eligibility.

• Evaluate provider qualifications and the services covered.

• Accurately enter and maintain comprehensive data, documentation, and notes in the claims administrative system.

• Track the aging of assigned tasks to ensure adherence to established turnaround time standards.

• Educate claimants and their representatives regarding policy coverage and the claims process.

• Act as the primary point of contact for claimants and/or their representatives, ensuring a positive and supportive experience.

• Contribute to process improvement initiatives by assisting in the development of enhanced customer service strategies.

• Keep updated on relevant state/territory regulations, industry trends, and emerging issues.

• Investigate and analyze medical evidence to determine if policy benefit qualifiers are satisfied.

• Consult with claimants’ physicians and/or providers as necessary to collect supporting medical information.

• Conduct telephonic evaluations to monitor claimants’ progress and assess changes in care needs over time.

• Identify and escalate claims that require special handling, including proposed denials, potential fraud, or coordination of benefits with other payers.

• Clinical Review Responsibilities.

• Review and summarize medical records to support claim evaluations.

• Evaluate complex medical claims upon request from non-clinical team members, offering clinical insights and guidance.

• Review claim files and complete Chronically Ill Certifications in accordance with policy requirements and regulatory standards.

⛳️ Requirements

• Professional designation required: Registered Nurse (RN) or Licensed Social Worker (LSW).

• Experience in LTC, disability, or related claims is preferred.

• A minimum of 2 years of claims experience is preferred.

• Strong knowledge of claims processes and/or the LTC insurance industry and practices.

• Solid understanding of medical terminology.

• Excellent verbal, written, and presentation skills, with the ability to communicate effectively across all corporate levels, as well as with providers, policyholders, and their representatives.

• Strong analytical and problem-solving abilities, capable of managing and prioritizing multiple claims and assigned projects.

• Proven ability to exercise independent judgment and make sound business decisions that support the merits of claims.

• Proficiency in Microsoft Office Products and other business-related software.

• Ability to quickly learn and adapt to new system applications.

• Flexible and adaptable to changes in a dynamic work environment.

🏝️ Benefits

• Medical, dental, and vision plans to support your health and that of your family.

• A 401(k) plan with employer matching.

• Time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non-exempt employees.

• Paid holidays.

• Life insurance and short-term and long-term disability coverage.

• Paid sick leave, paid family and parental leave, and other mandated benefits in accordance with applicable state and local requirements.