The Role
Evaluate and render eligibility decisions for long-term care and chronic illness claims per policy and client guidelines. Communicate with claimants, providers, and teams; verify provider licensure and services; document claim activity; create plans of care and complete chronic illness certifications while meeting quality, production, and compliance standards.
Summary Generated by Built In
Job Summary & Responsibilities
The nation's leading administrator of long term care insurance services is looking for YOU. This is your opportunity to join a company with a culture that promotes respect for people, integrity, learning and initiative.
WE ARE THE KIND OF EMPLOYER YOU DESERVE.
illumifin is a leading provider of business process outsourcing for the insurance industry, managing over 1.3 million long-term care policies for the nation's largest insurers. We also provide clients with unique risk management insight built upon our proprietary long term care databases.
The Claims Manager position is responsible for evaluation and rendering eligibility decisions on home and facility based Long Term Care claims (standalone and hybrid), chronic illness riders and/or critical illness within client contract and policy parameters, while providing quality customer service to our policy holders, their representatives and providers. A Claims Manager will be required to review and certify for chronic illness.
CLAIMS MANAGER RESPONSIBILITIES
WE ARE THE KIND OF EMPLOYER YOU DESERVE.
illumifin is a leading provider of business process outsourcing for the insurance industry, managing over 1.3 million long-term care policies for the nation's largest insurers. We also provide clients with unique risk management insight built upon our proprietary long term care databases.
The Claims Manager position is responsible for evaluation and rendering eligibility decisions on home and facility based Long Term Care claims (standalone and hybrid), chronic illness riders and/or critical illness within client contract and policy parameters, while providing quality customer service to our policy holders, their representatives and providers. A Claims Manager will be required to review and certify for chronic illness.
CLAIMS MANAGER RESPONSIBILITIES
- Review internal databases, client guidelines and policy contract language to evaluate routine home and facility-based claims, in accordance with department processes and standards.
- Communicate clearly and routinely with claimants, representatives, third parties, physicians and healthcare providers via written letters and phone calls as required by agreed upon SLAs and. Additionally, effectively communicate with team members and leadership on cases, as needed.
- Query service providers to obtain licensure information, proof of loss and dates of service. Verify that provider and/or care is appropriate base on the claimant’s diagnosis and is in accordance with contract language and government regulations regarding healthcare providers.
- Maintain clear and concise documentation of all claim activity within the required databases.
- Create plans of care and complete Chronic Illness Certification as appropriate.
- Provide prompt, courteous and excellent customer service to internal and external customers.
- Demonstrate effective communication skills, level of attentiveness and use of appropriate lines of authority. Promptly share accurate and complete information to others who need it, based on HIPAA and legal documents regarding release.
- Perform work accurately and demonstrate ability to prioritize workload.
- Participate in team meetings and assist colleagues with their work loads when appropriate.
- Uphold the principles of compliance as outlined in the Code of Conduct, Employee Handbook and related policies and procedures. Supports and participates in the mandatory Corporate Compliance Program training initiative on an annual or more frequent basis, as required.
- Meet established quality and production expectations as established and communicated by the department.
- Work independently with minimal direction.
- Other duties as assigned.
Minimum Qualifications
- Current and Unrestricted Registered Nurse (RN) or Social Work license.
- Four-year college degree or equivalent formal training program.
- Two years’ experience in medical, insurance or risk management setting.
- One-year work experience in claim processing.
- Intermediate level experience with Microsoft Office products.
- Excellent verbal and written communication.
Preferred Qualifications
- Experience working in a geriatric healthcare environment
- Knowledge of health, long-term care of disability insurance
The annual compensation target is at $60,000 depending on experience and qualifications
Skills Required
- Current and Unrestricted Registered Nurse (RN) or Social Work license.
- Four-year college degree or equivalent formal training program.
- Two years' experience in medical, insurance or risk management setting.
- One-year work experience in claim processing.
- Intermediate level experience with Microsoft Office products.
- Excellent verbal and written communication.
- Experience working in a geriatric healthcare environment.
- Knowledge of health, long-term care or disability insurance.
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The Company
What We Do
illumifin is an insurance technology company and third-party administrator that designs, develops, and delivers tech-enabled insurance policy management software and services. They focus on providing business processing services and innovative software solutions for the North American life, long-term care, annuity, and health insurance markets.
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