LTC Claims Pending Specialist - Remote USA.

Northwestern Mutual • Remote-Wisconsin, WI

1d • $60,880 - $105,000 • Remote

About The Position

This role is responsible for determining the applicability of benefits claimed by interpreting contract provisions, state regulations, and using claim knowledge to interpret and analyze facts to reach claim decisions on new and continuing claims, consistent with Northwestern Long Term Care's claim philosophy. The specialist will order and review medical, investigative, service provider, and other information to determine eligibility for long-term care claims and reimbursement of eligible expenses. They will also conduct interviews, answer incoming calls to explain claims status and contract provisions, and communicate effectively with various parties including insureds, their representatives, medical practitioners, and other insurance companies. This role involves negotiation and conflict resolution, preserving the company's image and reputation in claim decisions. Additionally, the specialist may participate in project and committee work as a Subject Matter Expert (SME), contribute to process improvements, and work cohesively with team members to meet team and division goals.

Requirements

• Healthcare background OR minimum 3+ years of long-term care insurance experience highly desirable
• A bachelor's degree or equivalent combination of education and work experience will be considered
• Experience with insurance claims is desirable
• Strong written and verbal communication skills required
• Strong technology skills required
• Ability to analyze medical records and draw out necessary information for claims processing
• Demonstrates initiative and strong support of team goals and results
• High degree of analytical skills, personal organization, and time management
• Strong client focus and customer service skills
• Ability to manage ambiguity and maintain a positive outlook in the face of change
• Ability to identify process improvement opportunities.

Nice To Haves

• Registered Nurse or Social Work license preferred

Responsibilities

• Determines the applicability of benefits claimed by interpreting contract provisions, state regulations, and uses claim knowledge in interpreting and analyzing facts to reach claim decisions on new and continuing claims, consistent with Northwestern Long Term Care's claim philosophy.
• Orders and reviews appropriate medical, investigative, service provider, and other information needed to determine the eligibility of long-term care claims including reimbursement of eligible expenses.
• Conduct interviews to gather pertinent claim information from the insured or their representative.
• Answer incoming calls from the field and insureds or their representatives to explain claims status, hypothetical claim situations, and contract provisions.
• Communicate effectively verbally and in writing with Insureds and their representatives, Field Force, medical practitioners, and related service providers, attorneys, other insurance companies, and divisional resources, is involves negotiation and conflict resolution.
• Preserves Northwestern Long Term Care's image and reputation in the approval or denial of benefits despite difficult and delicate circumstances.
• May be called upon for project and committee work as a Subject Matter Expert (SME), including the development of process improvements.
• Work cohesively with team members to meet the goals of the team and division.

Benefits

• The standard pay structure is listed but if you’re living in California, New York City or other eligible location, geographic specific pay structures, compensation and benefits could be applicable

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree