Eligibility Specialist 2, Claims

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

📋 Description

• Assess eligibility for Long-Term Care policy benefits in accordance with policy terms, company standards, and both state and federal regulations.

• Make decisions on eligibility approvals or denials along with associated benefits and riders.

• Analyze policy terms to ascertain claim benefits.

• Request evaluations from claimants and follow up for necessary medical records, forms, statements, certificates, and additional required information.

• Update systems and documentation throughout the eligibility assessment process.

• Review relevant reports and documents associated with eligibility determinations.

• Communicate promptly with claimants regarding decisions on benefit eligibility.

• Address inquiries from internal and external stakeholders concerning benefits, eligibility, claim payments, denials, and explanations of benefits.

• Document the rationale and basis for eligibility determinations in the appropriate systems.

• Collaborate with management, medical directors, and clients on intricate eligibility cases.

• Engage with other business units to collect and analyze data for claim adjudication and documentation.

• Carry out other assigned responsibilities.

⛳️ Requirements

• Stay updated on federal, state, and insurance regulations and requirements.

• Possess a working knowledge of the company’s claims and administrative software systems, as well as Microsoft applications.

• Maintain familiarity with all company services relevant to the business segment.

• Understand applicable company policies and procedures.

• Operate in compliance with company regulations concerning HIPAA, fraud, confidentiality, and private health information.

• Uphold client and company quality and production standards.

🏝️ Benefits

• [Insert benefits details here]

• [Insert additional benefits details here]