illumifin · 6 days ago
Claims Manager RN & MSW
Minnesota, United States
Full-time
Onsite
Mid LevelIllumifin is a leading provider of business process outsourcing for the insurance industry. The Claims Manager RN & MSW will be responsible for evaluating claims, communicating with stakeholders, and ensuring compliance with healthcare regulations while maintaining high standards of customer service.
ConsultingInformation TechnologyOutsourcing
Responsibilities
Reviews internal databases, client guidelines, and policy contract language to evaluate routine home and facility-based claims, in accordance with department processes and standards
Communicate clearly and routinely with claimants, representatives, third parties, physicians, and other health care providers as needed
Demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns from the claimant or representative
Queries service providers to obtain licensure information, proof of loss, and dates of service
Verifies that provider and/or care is appropriate base on the claimant’s diagnosis and is in accordance with contract language and government regulations regarding healthcare providers
Keeps clear and concise documentation of all claim activity within the required databases
Creates plans of care and refers for review and Chronic Illness Certification as appropriate
Uses time effectively to achieve expected productivity and efficiency
Demonstrates ability to prioritize workload
Performs work accurately and efficiently under deadline pressures
Always provides prompt, courteous and excellent customer service to internal and external customers
Demonstrates effective communication skills, level of attentiveness, and use of appropriate lines of authority
Promptly shares accurate and complete information to others who need it, based on HIPAA and legal documents regarding release
Attends or is responsible for information provided at meetings and through other organizational channels
Maintains appropriate organizational confidentiality
Communicates with other team members and management on cases as needed
Meets quality and production metrics as established and communicated by the department
Works independently and seeks assistance as appropriate
Qualification
Required
Registered Nurse (RN) or Master of Social Work (MSW) degree
Demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns from the claimant or representative
Ability to communicate clearly and routinely with claimants, representatives, third parties, physicians, and other health care providers as needed
Ability to query service providers to obtain licensure information, proof of loss, and dates of service
Ability to verify that provider and/or care is appropriate based on the claimant's diagnosis and is in accordance with contract language and government regulations regarding healthcare providers
Ability to keep clear and concise documentation of all claim activity within the required databases
Ability to create plans of care and refer for review and Chronic Illness Certification as appropriate
Ability to use time effectively to achieve expected productivity and efficiency
Demonstrated ability to prioritize workload and perform work accurately and efficiently under deadline pressures
Ability to provide prompt, courteous and excellent customer service to internal and external customers
Demonstrated effective communication skills, level of attentiveness, and use of appropriate lines of authority
Ability to promptly share accurate and complete information to others who need it, based on HIPAA and legal documents regarding release
Ability to attend or be responsible for information provided at meetings and through other organizational channels
Ability to maintain appropriate organizational confidentiality
Ability to communicate with other team members and management on cases as needed
Ability to meet quality and production metrics as established and communicated by the department
Ability to work independently and seek assistance as appropriate
Company
illumifin
illumifin provides third party administration and technology services to individual and group insurers.
Founded in 1919
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Blake Bostwick
President and Chief Operating Officer
Recent News
2025-03-06
2024-04-05
2024-01-09
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