Claims - Eligibility Specialist 2, Claims

Wellcove/CHCS-Services•Pensacola, FL

About The Position

This position is responsible for the review of policy benefit eligibility in accordance with policy, company, state, and federal guidelines. This position is for Long Term Care Insurance Plans administered by Prudential. Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs. Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.

Requirements

Excellent oral, written and interpersonal communication skills
Knowledge of Microsoft Office applications and telephone protocol
Exceptional listening and analytical skills
Strong knowledge of customer care processes and techniques
Demonstrated ability to work well in a team environment
Dedication to providing exceptional customer service
Proven leadership experience
Ability to provide and support company goals

Responsibilities

Responsible for accurate/timely daily review of Long-Term Care benefit eligibility in accordance with policy provisions to determine appropriate eligibility approval or denial.
Responsible for accurate/timely determination of benefits and additional benefits applicable under policy provisions such as Wavier of Premium, Inflation Protection Options, Guaranteed Purchase Options, and other applicable rider/policy benefits.
Responsible for interpreting policy provisions to accurately determine claim benefits in accordance with policy benefits
Responsible for timely request of claimant’s assessment and follow-up request of any/all required additional information, i.e., medical records, appropriate forms, statements, and certificates needed for proper eligibility determination
Ensure systems and documents are updated on all follow-ups and status throughout the eligibility process
Review and work other applicable reports and documents pertaining to eligibility determination
Responsible for sending correspondence timely to claimant about benefit eligibility determination
Respond appropriately and professionally to all oral and written external and/or internal correspondences received from stakeholders regarding benefits, eligibility, claim payments, denials and/or explanation of benefits
Ensure appropriate systems are updated timely and clearly regarding eligibility rationale on how determinations were made in accordance with policy provisions and documents received
Work with management, medical director, and client on review of complex eligibility cases
Maintain current knowledge of federal, state, and insurance regulations and requirements
Maintain working knowledge of all company and services pertaining to business segment
Maintain working knowledge and proficiency in company claims and administrative software systems as well as Microsoft applications
Maintain client and company quality and production standards
Maintain knowledge of applicable company policies and procedures
Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information
Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files