- 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
Core Competencies
Demonstrates expertise in Long-Term Care policy eligibility determination, ensuring compliance with federal, state, and insurance regulations. Proficient in managing claim processes, stakeholder communication, and documentation while maintaining high-quality standards.
Highest-signal resume keywords
- Eligibility Determination
- Claims Processing
- Regulatory Compliance
- Stakeholder Communication
- Documentation Management
Hard Skills
- Policy Interpretation
- Benefit Analysis
- Data Analysis
- Claims Adjudication
- Medical Record Review
Soft Skills
- Collaboration
- Attention to Detail
- Problem-Solving
- Time Management
Industry Keywords
- Long-Term Care
- HIPAA Compliance
- Insurance Regulations
- Eligibility Guidelines
Tools & Technologies
- Claims Software Systems
- Microsoft Applications
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Eligibility Specialist 2, Claims Arbeitgeber: Jobtailor
Als Front Office Supervisor in unserem dynamischen Team bieten wir Ihnen die Möglichkeit, in einem unterstützenden und freundlichen Arbeitsumfeld zu wachsen. Wir legen großen Wert auf die berufliche Entwicklung unserer Mitarbeiter und bieten regelmäßige Schulungen sowie die Chance, Verantwortung zu übernehmen. Unsere Lage ermöglicht es Ihnen, Teil einer lebendigen Gemeinschaft zu sein, während Sie gleichzeitig die Standards unseres Franchise-Partners einhalten und unseren Gästen einen unvergesslichen Aufenthalt bieten.
