Claims - Eligibility Specialist 2, Claims

Who We Are

Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs.

Job Summary 

This position is responsible for the review of policy benefit eligibility in accordance with policy, company, state, and federal guidelines.  This position is for Long-Term Care Insurance Plans. 

Supervisory Responsibilities: 

This job has no supervisory responsibilities. 

 Duties/Responsibilities: 

• Responsible for accurate/timely daily review of Long-Term Care benefit eligibility in accordance with policy provisions to determine appropriate eligibility approval or denial.  

• Responsible for accurate/timely determination of benefits and additional benefits applicable under policy provisions such as Wavier of Premium, Inflation Protection Options, Guaranteed Purchase Options, and other applicable rider/policy benefits. 

• Responsible for interpreting policy provisions to accurately determine claim benefits in accordance with policy benefits 

• Responsible for timely request of claimant’s assessment and follow-up request of any/all required additional information, i.e., medical records, appropriate forms, statements, and certificates needed for proper eligibility determination  

• Ensure systems and documents are updated on all follow-ups and status throughout the eligibility process 

• Review and work other applicable reports and documents pertaining to eligibility determination 

• Responsible for sending correspondence timely to claimant about benefit eligibility determination 

• Respond appropriately and professionally to all oral and written external and/or internal correspondences received from stakeholders regarding benefits, eligibility, claim payments, denials and/or explanation of benefits 

• Ensure appropriate systems are updated timely and clearly regarding eligibility rationale on how determinations were made in accordance with policy provisions and documents received 

• Work with management, medical director, and client on review of complex eligibility cases 

• Maintain current knowledge of federal, state, and insurance regulations and requirements 

• Maintain working knowledge of all company and services pertaining to business segment 

• Maintain working knowledge and proficiency in company claims and administrative software systems as well as Microsoft applications  

• Maintain client and company quality and production standards 

• Maintain knowledge of applicable company policies and procedures 

• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information 

• Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files 

• Other duties that are assigned