Claim Manager Clinician (Remote)

Key Responsibilities

• 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.

• 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. 

• 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. 

• 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.

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

Equal Employment Opportunity & Legal Notices

• 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