Claims - Support Representative, Claims

Job Summary

This position is responsible for the administrative support duties of most levels of claims in accordance with policy, company, state, and federal guidelines. This position is for Long Term Care Insurance Plans administered by Prudential.

Supervisory Responsibilities:

This job has no supervisory responsibilities.

 Duties/Responsibilities:

• Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files.
• Review requests involving Power of Attorney, Guardianship and Authorizations to Release Information.
• Assist the Claims team in requesting medical documentation to adequately adjudicate long-term care eligibility. Reviewing the documents received to determine if complete and accurate.
• Assist Claims Management with assigning work activities to associates within our workflow.
• Respond professionally and timely to customer inquiries.
• Ensure service calls are made in a timely, efficient and knowledgeable manner.
• Follow up on any outstanding documentation with additional correspondence, reviewing fax failures, and reviewing any returned mail.
• Contact providers and customers to obtain accurate contact information.

• 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.
• Other duties may be assigned

Required Skills/Abilities:

To perform this job successfully, the individual must be able to perform each essential duty effectively.  The individual must possess advance product knowledge, comprehensive understanding of insurance terminology and definitions, core knowledge of company and department processes and procedures related to the ability to complete job responsibilities /duties in a proficient and professional manner. 

Ability to read, analyze, and interpret complex documents; ability to respond effectively to the most sensitive inquiries or complaints; ability to write policies and procedures; ability to make effective presentations; ability to exhibit excellent verbal and written communication skills

Customer Service; Work Standards; Decision-Making; Communication; Interpersonal Skills; Integrity/Honesty and Adaptability/Flexibility

Must have the ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals; Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.

Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form; Ability to deal with problems involving several concrete variables in standardized situations.

Education and Experience:

High School diploma required and previous experience in the Long-Term Care insurance industry and/or administrative preferred but not required. 

Physical Requirements:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit; use hands to finger, handle, or feel; and talk or hear.  The employee is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl.  The employee must occasionally lift and/or move up to 10 pounds.  Specific vision abilities required by this job include close vision, distance vision, color vision, and ability to adjust focus.

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.