Claims Eligibility Specialist - Clinical

Continental General; Austin (TX); Hybrid; USD 60,000 - 80,000; Full time

Benefits offered by this job

Competitive salaries

Culture of learning

Flexible working arrangements

Job summary

A growing insurance company in Austin, Texas is seeking a Claims Eligibility Specialist - Clinical to review and manage long term care claims. Candidates should have at least 5 years of experience in claims management and possess a bachelor's degree in a relevant field. This hybrid position offers competitive salaries and a collaborative work environment, making it an exciting opportunity for individuals who are looking to enhance their careers while making a difference in others' lives.

Qualifications

• 5+ years of related experience in claims management and review.
• Experience in the insurance industry and related products is a plus.
• Strong technical knowledge and skills related to claims management and review.

Responsibilities

• Investigate and support in managing cases of varying complexity.
• Review and evaluate coverage and/or liability.
• Analyze information to determine eligibility for long term care claims.
• Establish Plan of Care according to Claim Handling Guidelines.
• Manage short-term/limited approval claims.
• Assist with complaints/appeals.

Skills

Claims management

Effective communication

Empathy

Technical knowledge of insurance

Ability to work under limited supervision

Education

Bachelor’s degree in LVN, LPN, LSW, Business or related field

Job description

CLAIMS ELIGIBILITY SPECIALIST - CLINICAL

(Full Time, Hourly, Non-Exempt)

Looking to join a growing company dedicated to helping others? We offer that, plus competitive salaries, a culture of learning, and a fast-paced environment. This is a hybrid position with 3 days in-office. Join our team to help make a difference in the lives of others! We are also open to remote candidates!

About Continental General:

The Continental General family of companies has provided insurance, including life and long-term care policies, to individuals and groups for over 30 years, and currently supports over 100,000 policyholders. Both our insurance company, Continental General Insurance Company, and our third-party administrator, Continental General Services, are committed to the continuous development of our infrastructure, processes, and people. The group is actively growing through expansion of both its insurance portfolio and its administrative services. With each opportunity, we take a collaborative approach to address challenges and provide unique solutions.

Position Overview:

As a Long Term Care Claims Eligibility Specialist - Clinical, you will play a critical role in reviewing and managing claims of varying complexity. You’ll work closely with a collaborative team, supporting the accurate and timely processing of long term care claims while ensuring a high-quality customer experience. This is a great opportunity for someone with a strong background in claims and a desire to grow in a fast-paced, mission-driven environment.

Key Responsibilities:

Investigates, maintains, and supports others in managing cases of varying complexity, including but not limited to:

• Reviews and evaluates coverage and / or liability.
• Analyzes necessary information (i.e., reports, policies, appraisals, releases, statements, records, or other documents) to determine eligibility for long term care claims.
• Establishes appropriate Plan of Care according to Claim Handling Guidelines
• Manages short-term/limited approval claims.
• Assists with complaints/appeals.
• Conveys more complex information (coverage, decisions, outcomes, etc.) to all appropriate parties, maintaining a professional demeanor in all situations.
• Ensures claims handling is conducted in compliance with applicable statues, regulations, and other legal requirements, and that all applicable company procedures and policies are followed.
• Works closely with Team Lead(s), and can provide back up support to the Team Lead(s)
• Provides guidance and support to lower-level positions and other functional areas
• Performs other duties as assigned.

Qualifications:

• 5+ years of related experience in claims management and review, with experience in the insurance industry and with related products a plus.
• Bachelor’s degree in LVN, LPN, LSW, Business or a related field, or the equivalent years of education and experience required
• Possesses a high level of technical knowledge and skills related to claims management and review
• Communicates effectively, both orally and in writing, with empathy and strong listening skills
• Performs work under limited supervision.