Claims - Care Manager, RN, Claims

Wellcove; Pensacola (FL); On-site; USD 65,000 - 90,000; Full time

Job summary

Wellcove seeks an experienced Registered Nurse (RN) to act as a Care Manager supporting Long Term Care insurance claims in Pensacola. This individual contributor role conducts comprehensive clinical eligibility reviews and documents Chronically Ill Certifications and Plans of Care for initial and recertification activities.

The RN will collaborate with Claims, Eligibility, and Customer Service teams, review MDS assessments and medical records, and stay current on LTC policy language and

Qualifications

• Active, unrestricted RN license.
• Experience in long-term care, home health, geriatrics, case management or utilization review.
• Experience reviewing medical records and assessing functional and cognitive impairment.
• Knowledge of LTC policy language, benefit triggers, and chronically ill certification standards.
• Strong clinical judgment, critical thinking, and documentation skills.

Responsibilities

• Perform detailed clinical reviews of LTC claim files to determine eligibility.
• Assess ADLs, cognitive impairment, diagnoses, comorbidities, and level of care needs.
• Review medical records, MDS assessments, facility documentation, home health records, daily notes, and claim forms.
• Determine whether the insured meets the policy definition of Chronically Ill.
• Prepare and document Chronically Ill Certifications (CICs) and Plans of Care (POCs).
• Document clinical rationale to support benefit determinations.
• Collaborate with Claims, Eligibility, and Customer Service teams to obtain documentation.
• Maintain knowledge of LTC policy language, benefit triggers, and regulatory requirements.

Skills

RN license

Geriatrics

Case management

Utilization review

Documentation

ADL assessment

MDS knowledge

Education

Bachelor of Science in Nursing (BSN)

Tools

EHR systems

Job description

Wellcove-Pensacola, 4900 BAYOU BLVD, PENSACOLA, Florida, United States of America

Job Description

Who We Are

Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs.

Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.

We are seeking an experienced Registered Nurse (RN) to serve as a Care Manager supporting Long Term Care (LTC) insurance claims. This individual contributor role is responsible for conducting comprehensive clinical eligibility reviews to determine whether policyholders meet the benefit eligibility requirements outlined in their LTC policy.

The Care Manager, RN will complete and document Chronically Ill Certifications (CICs) and develop Plans of Care (POCs) for initial claims and ongoing recertifications, ensuring determinations are clinically sound, and policy aligned.

Key Responsibilities

Perform detailed clinical reviews of LTC claim files to determine eligibility in accordance with policy provisions and regulatory requirements.

Assess Activities of Daily Living (ADLs), cognitive impairment, diagnoses, comorbidities, and level of care needs.

Review medical records, Minimum Data Set (MDS) assessments, facility documentation, home health records, daily visit notes, and supporting claim forms.

Determine whether the insured meets the policy definition of Chronically Ill.

Prepare and document Chronically Ill Certifications (CICs) and individualized Plans of Care (POCs) for initial approvals and recertifications.

Clearly document clinical rationale to support benefit determinations.

Collaborate with Claims, Eligibility, and Customer Service teams to obtain additional documentation when necessary.

Maintain knowledge of LTC policy language, benefit triggers, and regulatory requirements.

Qualifications

Active, unrestricted Registered Nurse (RN) license required.

Clinical experience in long-term care, home health, geriatrics, case management, or utilization review preferred.

Experience reviewing medical records and assessing functional and cognitive impairment.

Knowledge of LTC insurance benefit triggers, ADL requirements, and chronically ill certification standards preferred.

Strong clinical judgment, critical thinking, and documentation skills.

Ability to manage multiple cases and meet turnaround expectations.

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.

Wellcove-Pensacola, 4900 BAYOU BLVD, PENSACOLA, Florida, United States of America