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Continental General Insurance

Long Term Care Claims Eligibility Specialist - Clinical

Claims AdjudicationConfirmed live in the last 24 hours
Full-timeAustin, TX, USA

About the Job

Requirements

  • At least 5 years of related experience in claims management and review; insurance-industry and related-products experience is a plus.
  • A bachelor's degree in LVN, LPN, LSW, Business, or a related field, or equivalent years of education and experience.
  • Possesses a high level of technical knowledge and skills related to claims management and review.
  • Communicates effectively, orally and in writing, with empathy and strong listening skills.
  • Performs work under limited supervision.

Responsibilities

  • Investigates, maintains, and supports others in managing cases of varying complexity.
  • Reviews and evaluates coverage or liability.
  • Analyzes reports, policies, appraisals, releases, statements, records, and other documents to determine eligibility for long-term care claims.
  • Establishes an appropriate Plan of Care according to Claim Handling Guidelines.
  • Manages short-term or limited-approval claims.
  • Assists with complaints and appeals.
  • Conveys complex information, including coverage, decisions, and outcomes, to appropriate parties while maintaining a professional demeanor.
  • Ensures claim handling complies with applicable statutes, regulations, legal requirements, company procedures, and policies.
  • Works closely with team leads and provides backup support to them.
  • Provides guidance and support to lower-level positions and other functional areas.
  • Performs other duties as assigned.

Desired Qualifications

  • Experience in the insurance industry and with related products.

About the Company

Continental General Insurance

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