Eligibility Specialist 2, Claims

Stellenbeschreibung:

Review Long-Term Care policy benefit eligibility according to policy, company, state, and federal guidelines
Determine eligibility approval or denial and applicable benefits and riders
Interpret policy provisions to determine claim benefits
Request claimant assessments and follow up for medical records, forms, statements, certificates, and other required information
Update systems and documents throughout the eligibility process
Review applicable reports and documents related to eligibility determination
Send timely correspondence to claimants about benefit eligibility determinations
Respond to internal and external stakeholder correspondence regarding benefits, eligibility, claim payments, denials, and explanations of benefits
Document eligibility rationale and determination basis in appropriate systems
Collaborate with management, medical directors, and clients on complex eligibility cases
Interact with other business units to gather and analyze data for claim adjudication and claim-file documentation
Perform other assigned duties

Requirements

Maintain current knowledge of federal, state, and insurance regulations and requirements
Maintain working knowledge of company claims and administrative software systems and Microsoft applications
Maintain working knowledge of all company and services pertaining to the business segment
Maintain knowledge of applicable company policies and procedures
Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information
Maintain client and company quality and production standards

Core Competencies

Demonstrates expertise in Long-Term Care policy eligibility determination, ensuring compliance with federal, state, and insurance regulations. Proficient in managing claim processes, stakeholder communication, and documentation while maintaining high-quality standards.