Eligibility Specialist 2, Claims

Job not on LinkedIn

🔥 1 minute ago

🐊 Florida – Remote

🐊 Florida – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Wellcove

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1989

🛡️ Insurance

🏥 Healthcare

☁️ SaaS

Insurance • Healthcare • SaaS

Wellcove is a third‑party administrator (TPA) focused on the senior market and long‑term care (LTC) benefits. Its cloud‑native LTC Now platform and AssuriCare services provide automated claim administration, eligibility determination, auto‑adjudication, payment processing, digital care management, provider matching, risk evaluation/analytics, and business process outsourcing for carriers, state retirement plans, and reinsurers. The company emphasizes automation, payment integrity, and tailored administrative solutions for long‑term care and Medicare supplement administration.

📋 Description

• 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