Claim Manager Clinician (Remote)

Department: Claims Administration & Adjusting

Employment Type: Permanent - Full Time

Location: Home United States

Reporting To: Shelly Leshko

Compensation: $38.45 - $43.25 / hour

Description

What's in Store
We are on the lookout for a Claim Manager Clinician to join our team. The Claim Manager Clinician (CMC) is a Registered Professional Nurse or Licensed Social Worker responsible for managing a daily caseload of Long Term Care (LTC) Claims in a fast-paced, remote office environment. Using established claim policies and guidelines, the CMC evaluates claims to determine whether the Insured is benefit qualified and receiving covered services from an eligible provider. The CMC also educates policyholders on their coverage and communicates directly with service providers and physicians to facilitate claim resolution.

Key Responsibilities

1) Determine eligibility of LTC claims to individualized policy

• Interpret LTC policy coverage using claims guidelines and policy language to assess eligibility.
• Evaluate provider qualifications and covered services.
• Accurately input and maintain complete data, documentation, and notes in the claims administrative system.
• Monitor the aging of assigned tasks to ensure compliance with established turnaround time standards.

2) Educates claimants and their representatives on policy coverage and claim processes

• Serve as the point of contact for claimants and/or their representatives, ensuring a positive and supportive experience.
• Contribute to process improvement initiatives by helping develop enhanced customer service strategies.
• Stay current on relevant state/territory regulations, industry trends, and emerging issues.

3) Investigate and analyze medical evidence to determine whether policy benefit qualifier(s) are met

• Consult with claimants' physicians and/or providers as needed to gather supporting medical information.
• Conduct telephonic evaluations to monitor claimants' progress and assess changes in care needs over time.
• Identify and escalate claims requiring special handling, including proposed denials, potential fraud, or coordination of benefits with other payers.

4) Clinical Review Responsibilities

• Review and summarize medical records to support claim evaluations.
• Assess complex medical claims upon request from non-clinical team members, providing clinical insight and guidance.
• Review claim filles and complete Chronically Ill Certifications in accordance with policy requirements and regulatory standards.

5) May perform additional duties as assigned.

This a full-time, remote role.

Skills, knowledge & expertise

• Professional designation required: Registered Nurse (RN) or Licensed Social Worker (LSW)
• Experience in LTC, disability, or related claims is preferred
• Minimum of 2 years claims experience is preferred
• Strong knowledge of claims processes and/or LTC insurance industry and practices
• Solid understanding of medical terminology
• Excellent verbal, written and presentation skills, with the ability to communicate effectively across all corporate levels, as well as with providers, policyholders and their representatives
• Strong analytical and problem-solving skills, with ability to manage and prioritize multiple claims and assigned projects
• Demonstrated ability to exercise independent judgment and make sound business decisions that support the merits of claims
• Proficiency in Microsoft Office Products and other business-related software
• Ability to quickly learn and adapt to new system applications
• Flexible and adaptable to change in a dynamic work environment

Benefits

At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:

• Medical, dental, and vision plans to support your health and that of your family
• A 401(k) plan with employer matching
• Time-off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non-exempt employees
• Paid holidays
• Life insurance and short-term and long-term disability coverage

Benefit offerings, eligibility, and required employer contributions may vary based on role, classification, and applicable federal, state, and local laws, including those tied to an employee's primary work location.

Where required by law, the Company provides paid sick leave, paid family and parental leave, and other mandated benefits in accordance with applicable state and local requirements.

Compensation Transparency:
The salary range listed reflects the full compensation band for this role across all locations. Actual compensation will be based on factors such as skills, experience, qualifications, and geographic location, which may impact the final offer. We share ranges to remain transparent and consistent with pay equity practices.