Thrivent · 9 hours ago

Claims Examiner, Long Term Care

United States

Full-time

Remote

Entry, Mid Level

$23.59/hr - $31.92/hr

2+ years exp

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Responsibilities

Determine extent of liability on routine and non-routine claims and make final claim decisions within specified dollar limits. Contribute to accurate fraud detection and reporting by referring suspected fraud to appropriate staff for review according to established procedures.

Analyze claim transactions and process payments utilizing various work flow, administrative, and LOB (Line of Business) systems, accurately and cost effectively according to contract provisions and in compliance with internal service and state and federal regulatory standards.

Ensure high level of customer satisfaction by partnering with members, financial associates, doctors, providers, attorneys, police, vendors and other internal and external customers regarding claims, settlements and interpretation of policy provisions, which may include highly confidential information or complaints, often educating the recipient on products/benefits and regulatory requirements.

Handle sensitive written and verbal communications. May be called upon to influence behavior via these communications.

Actively participate in the development and implementation of business processes, standard operating procedures, documentation and other support materials required for unit operation. May also analyze data and offer remediation in response to audit inquiries or compliance examinations as determined by the Claims Consultant.

Provide consultation to Associate Claims Examiners in helping to answer questions and make decisions on claims with a moderate level of complexity.

Qualification

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Claim administrationRegulatory complianceFraud detectionLOMA certificationICA certificationData analysisProcess improvement