Specialist

Highly specialized job function that is responsible for claim analysis and claim processing for long term care services.  This position is also accountable for reviewing claims for accuracy, timeliness, completeness and eligibility for multiple groups with varied benefits..

Job Responsibilities

• Analyze and process claims in a productive environment through our TLC claim system, SIR, plan specs and

specimen policy

• Appropriately interpret a variety of plan provisions and process claims accordingly, calculating claim payments and

overpayments

• Review claims for receipt of all needed documentation and make outbound calls to providers for additional

information

• Collaborate with our Claim Support Specialists, Customer Call Center and Care Coordinators to provide a seamless

        claims experience

• Abide by department guidelines and appropriately follow up on necessary tasks to process claims

• Meet quality review standards of processed claims

• Meet performance standards for financial accuracy, processing accuracy and claim timeliness

Respond to insured inquiries regarding specific claim details via telephone conversations and/or written

correspondence

• Gather and analyze information skillfully to identify and resolve problems in a timely manner