Claims - Claims Examiner

Wellcove/CHCS-Services•Pensacola, FL

About The Position

The Long-Term Care (LTC) Claims Examiner is responsible for the accurate and timely adjudication of long-term care insurance claims. This role ensures compliance with policy provisions, regulatory requirements, and company standards while delivering a high level of customer service to policyholders, providers, and internal stakeholders.

Requirements

High school diploma or equivalent required
2+ years of experience in insurance claims, healthcare administration, or Long-Term Care claims processing
Knowledge of medical terminology and healthcare documentation
Proficiency in claims systems and Microsoft Office (Excel, Word, Outlook)
Strong analytical and decision-making skills
Excellent written and verbal communication skills
Ability to manage multiple priorities in a fast-paced environment

Nice To Haves

associate or bachelor’s degree preferred
Strong understanding of Long-Term Care policies, benefits, and eligibility criteria preferred

Responsibilities

Review, evaluate, and adjudicate Long Term Care claims in accordance with policy provisions and established guidelines
Analyze claim documentation including invoices, care plans, and provider credentials
Apply knowledge of Coordination of Benefits (COB), Medicare, Medicaid, and other payer sources when applicable
Ensure claims are processed within established turnaround times and service level agreements (SLAs)
Communicate effectively with policyholders, providers, and internal teams regarding claim status, requirements, and determinations
Identify and request additional documentation when necessary to support claim decisions
Maintain accurate and detailed claim notes in system of record
Ensure compliance with HIPAA and all applicable regulatory and privacy requirements
Participate in quality assurance activities and implement feedback for continuous improvement
Support training and mentoring of new or junior staff as needed