LTC Claims Examiner: Detail-Driven Adjudicator

Wellcove; Pensacola (FL); On-site; USD 45,000 - 65,000; Full time

Job summary

Wellcove in Pensacola, FL is seeking a Long-Term Care Claims Examiner to adjudicate LTC claims with accuracy and timeliness in a regulated environment.

You will review documentation, apply COB/Medicare/Medicaid knowledge, and communicate with policyholders, providers, and internal teams while maintaining HIPAA compliance and striving for service excellence. This role requires 2+ years in insurance claims or healthcare administration and a high school diploma (bachelor preferred).

Qualifications

• 2+ years of experience in insurance claims, healthcare administration, or Long-Term Care claims processing.
• Strong understanding of Long-Term Care policies, benefits, and eligibility criteria preferred.
• Knowledge of medical terminology and healthcare documentation.
• Proficiency in claims systems and Microsoft Office (Excel, Word, Outlook).
• Strong analytical and decision-making skills.
• Excellent written and verbal communication skills.
• Ability to manage multiple priorities in a fast-paced environment.

Responsibilities

• Review, evaluate, and adjudicate Long Term Care claims in accordance with policy provisions and established guidelines.
• Analyze claim documentation including invoices, care plans, and provider credentials.
• Apply knowledge of Coordination of Benefits (COB), Medicare, Medicaid, and other payer sources when applicable.
• Ensure claims are processed within established turnaround times and service level agreements (SLAs).
• Communicate effectively with policyholders, providers, and internal teams regarding claim status, requirements, and determinations.
• Identify and request additional documentation when necessary to support claim decisions.
• Maintain accurate and detailed claim notes in system of record.
• Ensure compliance with HIPAA and all applicable regulatory and privacy requirements.
• Participate in quality assurance activities and implement feedback for continuous improvement.
• Support training and mentoring of new or junior staff as needed.

Skills

Analytical thinking

Decision making

Written and verbal communication

Multitasking in fast-paced environment

Education

High school diploma or equivalent

Associate or bachelor’s degree preferred

Tools

Microsoft Office

Claims processing systems

HIPAA compliance tools

Job description

Wellcove in Pensacola, FL is seeking a Long-Term Care Claims Examiner to adjudicate LTC claims with accuracy and timeliness in a regulated environment.

You will review documentation, apply COB/Medicare/Medicaid knowledge, and communicate with policyholders, providers, and internal teams while maintaining HIPAA compliance and striving for service excellence. This role requires 2+ years in insurance claims or healthcare administration and a high school diploma (bachelor preferred).