Claims Eligibility Specialist - Clinical

Continental General; Austin (TX); Hybrid; USD 30,000 - 39,000; Full time

Job summary

Continental General is seeking a Claims Eligibility Specialist - Clinical in a hybrid role. You will review and manage long term care claims, determine eligibility, and collaborate with a team to ensure accurate processing and a positive customer experience.

This is a full-time, hourly, non-exempt position with 3 days in-office and open to remote candidates. The role requires 5+ years in claims, a related degree, and strong communication.

Qualifications

• 5+ years of related experience in claims management.
• Bachelor’s degree in LVN/LPN/LSW or related field or equivalent experience.
• Strong written and verbal communication with empathy.
• Performs work with limited supervision.

Responsibilities

• Investigates and supports cases of varying complexity.
• Reviews eligibility for long term care claims.
• Establishes Plan of Care per guidelines.
• Manages short-term/limited approval claims.
• Assists with complaints/appeals and communicates outcomes.
• Ensures compliance with applicable statutes, regulations, and policies.
• Works with Team Lead(s) and provides back-up support.
• Guides lower-level positions and other areas.
• Performs other duties as assigned.

Skills

Empathy communication

Claims analysis

Regulatory knowledge

Team guidance

Education

Bachelor's degree 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.