Claim Manager, Clinician

Vaga não está no LinkedIn

🕒 4 dias atrás

🏈 Alabama – Remoto

🏈 Alabama – Remote

💵 $38 - $43 / hora

⏰ Tempo Integral

🟢 Júnior

🟡 Pleno

👔 Gerente

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MDD Forensic Accountants

SiteLinkedInTodas as Vagas

201 - 500 funcionários

Fundada em 1933

💸 Finanças

Finance • Insurance • Consulting

A MDD Forensic Accountants é uma empresa de perícia contábil especializada em avaliação de empresas, disputas societárias entre acionistas e quantificação de danos econômicos. Com mais de 40 escritórios no mundo, a MDD oferece expertise em uma ampla variedade de setores, prestando serviços a seguradoras, escritórios de advocacia, governos e pessoas físicas. Seus serviços incluem interrupção de negócios, lucros cessantes, investigações de fraude e outros, tornando-a uma assessora de confiança para decisões financeiras sólidas.

Descrição

• Determine eligibility of LTC claims to individualized policy • Interpret LTC policy coverage using claims guidelines and policy language to assess eligibility. • Evaluate provider qualifications and covered services. • Accurately input and maintain complete data, documentation, and notes in the claims administrative system. • Monitor the aging of assigned tasks to ensure compliance with established turnaround time standards. • Educates claimants and their representatives on policy coverage and claim processes • Serve as the point of contact for claimants and/or their representatives, ensuring a positive and supportive experience. • Contribute to process improvement initiatives by helping develop enhanced customer service strategies. • Stay current on relevant state/territory regulations, industry trends, and emerging issues. • Investigate and analyze medical evidence to determine whether policy benefit qualifier(s) are met. • Consult with claimants’ physicians and/or providers as needed to gather supporting medical information. • Conduct telephonic evaluations to monitor claimants’ progress and assess changes in care needs over time. • Identify and escalate claims requiring special handling, including proposed denials, potential fraud, or coordination of benefits with other payers. • Clinical Review Responsibilities • Review and summarize medical records to support claim evaluations. • Assess complex medical claims upon request from non-clinical team members, providing clinical insight and guidance. • Review claim files and complete Chronically Ill Certifications in accordance with policy requirements and regulatory standards.

🎯 Requisitos

• Professional designation required: Registered Nurse (RN) or Licensed Social Worker (LSW) • Experience in LTC, disability, or related claims is preferred • Minimum of 2 years claims experience is preferred • Strong knowledge of claims processes and/or LTC insurance industry and practices • Solid understanding of medical terminology • Excellent verbal, written and presentation skills, with the ability to communicate effectively across all corporate levels, as well as with providers, policyholders and their representatives • Strong analytical and problem-solving skills, with ability to manage and prioritize multiple claims and assigned projects • Demonstrated ability to exercise independent judgment and make sound business decisions that support the merits of claims • Proficiency in Microsoft Office Products and other business-related software • Ability to quickly learn and adapt to new system applications • Flexible and adaptable to change in a dynamic work environment

🏖️ Benefícios

• Medical, dental, and vision plans to support your health and that of your family • A 401(k) plan with employer matching • Time‑off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non‑exempt employees • Paid holidays • Life insurance and short‑term and long‑term disability coverage • Paid sick leave, paid family and parental leave, and other mandated benefits in accordance with applicable state and local requirements