Claim Manager Clinician (Insurance)

TL;DR

Claim Manager Clinician (Insurance): Managing a daily caseload of Long Term Care (LTC) claims to determine benefit eligibility and coverage with an accent on clinical evidence analysis and policy interpretation. Focus on evaluating medical records, conducting telephonic assessments, and ensuring regulatory compliance in claim resolutions.

Location: Remote (Must be based in the United States)

Salary: $38.45 - $43.25 / hour

Company

Specialist professional services and technology firm partnering with leading insurance and regulated businesses to manage risk and transform core business processes.

What you will do

• Interpret LTC policy language and guidelines to assess claim eligibility and provider qualifications.
• Analyze medical evidence and summarize records to support clinical claim evaluations.
• Educate policyholders and their representatives on coverage and claim processes.
• Conduct telephonic evaluations to monitor claimant progress and assess changes in care needs.
• Collaborate with physicians and providers to gather necessary supporting medical documentation.
• Identify and escalate claims requiring special handling, including potential fraud or coordination of benefits.

Requirements

• Professional designation: Registered Nurse (RN) or Licensed Social Worker (LSW).
• Minimum of 2 years of claims experience (preferred).
• Experience in Long Term Care (LTC) or disability claims (preferred).
• Strong understanding of medical terminology and claims processes.
• Proficiency in Microsoft Office and ability to quickly adapt to new system applications.
• Must be based in the United States.

Culture & Benefits

• Comprehensive medical, dental, and vision insurance plans.
• 401(k) plan with employer matching.
• Time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non-exempt employees.
• Life insurance and short-term and long-term disability coverage.
• Paid holidays and a commitment to fostering a diverse and inclusive workplace.