LTC Claims Pending Specialist

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

📋 Description

• Assesses the validity of claimed benefits by interpreting contract details, state regulations, and leveraging claim expertise to analyze facts for decision-making on both new and ongoing claims.

• Requests and evaluates necessary medical, investigative, service provider, and other relevant information to establish the eligibility of long-term care claims, including the reimbursement of qualifying expenses.

• Conducts interviews to collect essential claim information from the insured or their representative.

• Responds to incoming inquiries from the field, insured individuals, or their representatives to clarify claims status, hypothetical claim scenarios, and contract terms.

• Effectively communicates, both verbally and in writing, with insured individuals and their representatives, field personnel, medical professionals, related service providers, attorneys, other insurance companies, and divisional resources, which involves negotiation and conflict resolution.

• Maintains the reputation and image of Northwestern Long Term Care when approving or denying benefits, even in challenging and sensitive situations.

• May be asked to contribute as a Subject Matter Expert (SME) for project and committee initiatives, including the development of process enhancements.

• Collaborates effectively with team members to achieve the objectives of the team and division.

⛳️ Requirements

• A Registered Nurse or Social Work license is preferred.

• A background in healthcare or a minimum of 3+ years of experience in long-term care insurance is highly desirable.

• A bachelor's degree or an equivalent combination of education and work experience will be considered.

• Experience with insurance claims is preferred.

• Strong written and verbal communication skills are essential.

• Proficient technology skills are required.

• Ability to analyze medical records and extract necessary information for claims processing.

• Demonstrates initiative and a strong commitment to team goals and outcomes.

• High level of analytical skills, personal organization, and time management is essential.

• Strong client focus and customer service skills are necessary.

• Ability to navigate uncertainty and maintain a positive attitude amidst change.

• Capability to identify opportunities for process improvement.

🏝️ Benefits

• Health insurance

• Retirement plans

• Paid time off

• Flexible work arrangements

• Professional development