Claim Manager I

Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

What’s in Store 

We are on the lookout for an experienced and professional Claim Manager who will be responsible for managing a daily caseload of Long-Term Care (LTC) Claims in a fast-paced environment. As the Claim Manager, you will utilize claim policies and guidelines to assesses claims to determine if the Insured is benefit qualified and receiving covered services from a qualified provider. You will be responsible for educating policyholders on Policy coverage and will correspond directly with service providers and physicians to resolve claims. You must possess a high degree of empathy and professionalism, possess strong analytical and problem-solving skills, and can work both independently and as a team. 

Key responsibilities include: 

• Use claims guidelines and policy language to interpret LTC policy coverage to determine eligibility
• Evaluate provider qualification and covered services
• Input accurate and complete data, information, and notes into the claims administrative system to document eligibility
• Monitor aging of assigned tasks to ensure established turnaround time standards are met
• Educate claimants and their representatives on policy coverage and claim processes
• Serve as point of contact for claimants and/or their representatives ensuring a positive experience
• Keeps current on state/territory regulations and issues as well as industry activities and trends
• Investigate and analyze medical evidence to determine whether policy benefit qualifier(s) are met
• Consult with claimant’s physician and/or providers as required
• Perform telephonic evaluation of claimant to track progress and determine if care needs change over time, as needed
• Identify claims for escalation and special handling including proposed denials, fraud, and coordination of benefits with other payer sources
• Appropriately process all confidential information abiding by HIPAA privacy laws
• Support company values of We are Dynamic, We are Innovative, We are Connected, and We Succeed Together
• Perform other duties as assigned

This is a full-time, home-based position.

Your Expertise, Skills, and Abilities

• High School diploma/GED required or an equivalent combination of education and experience
• A minimum of 1-3 years of claims experience 
• Insurance Industry knowledge (LTC, Disability, Major Medical, etc.) preferred
• Understanding of medical terminology preferred
• Possess a high degree of tact, empathy, and professionalism 
• Strong analytical and problem-solving skills with ability to manage and prioritize multiple claims, as well as assigned projects
• Exceptional interpersonal skills with an enthusiastic nature and an overall passion for excellence
• Ability to apply learned principles to specific and unique circumstances
• Superb written, telephonic, and verbal communication skills; must be clear and concise
• Detail oriented with the ability to work independently as well as part of a team
• Solid knowledge of Microsoft Office products with ability to learn new system applications quickly
• Exceptional attention to detail with excellent organizational skills
• Solid knowledge of claims and/or long-term care insurance industry and practices

Benefits

At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:

• Medical, dental, and vision plans to ensure your health and that of your family.
• A 401k plan with employer matching to help you build a secure financial future.
• Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
• Paid holidays.
• Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.

Diversity and Inclusion

Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.