Offer summary

Qualifications:

Bachelor's degree in a relevant field or equivalent experience., Strong understanding of medical records and eligibility assessment processes., Excellent verbal and written communication skills., Ability to analyze and interpret state-specific regulations and provider credentials..

Key responsabilities:

Assess claimant eligibility through medical record reviews and phone assessments.

Determine legitimacy of service providers by reviewing licensing credentials and conducting assessments.

Communicate the claim benefit determination process effectively to claimants and stakeholders.

Monitor reports to ensure timely handling of claims and attend case conferences to present recommendations.

Job description

illumifin is a leading provider of business process outsourcing for the insurance industry, managing over 1.3 million long-term care policies for the nation's largest insurers. We also provide clients with unique risk management insight built upon our proprietary long term care databases.

This position is responsible for gathering and reviewing requirements for the purpose of determining initial and ongoing claimant and provider eligibility.

Responsibilities

Assess claimant eligibility by reviewing medical records from all current providers and conducting phone assessments with the claimant or legal representative. In the event of noted inconsistencies in the claimant eligibility, coordinate a benefit eligibility assessment in order to make a final determination.
In conjunction with plan language upon initial assessment and ongoing recertification, determine legitimacy and eligibility of service providers by requesting and reviewing provider licensing credentials, state-specific regulations, internet searches and phone assessments with the servicing provider.
Effectively communicate, verbal and written, all aspects of the claim benefit determination process.
Assist claimants with modifications to their current care plan, including changes in care needs as well as changes in provider.
Monitor daily, weekly and monthly reports to ensure claims are handled timely and appropriately.
Attend case conferences, internally and with the client, to present claims recommendations.
Meet quality and production metrics as established and communicated by the department.
Reviews Care Coordinator decision recommendations on tax qualified policies.
Other duties as assigned.

Required profile