Description et exigences
Job Description LTC Claims – Plan of Care
Position Title:
Senior Case Management Specialist
Function, Responsibility Level:
Operations, Executive
Reports to (Responsibility Level):
AM
Supervises:
Individual Contributor
Location:
MGOSC MCC1
Global Grade:
Grade 9
Cost Center (85 series):
NA
Complexity:
C5T4
PID/s Load Mapping:
NA
Role Value Proposition
Provides administration of benefits for Long-Term Care Insurance. Administration includes determination of benefit eligibility,
information and referral, care management, insured advocacy, provider verification, claim processing and customer service.
Roles & Responsibilities
• Handles incoming calls through the claim toll free lines.
• Provides plan and claim information, assists with submission of claims and makes outbound calls to gather missing
information on incomplete claims.
• Conducts research when needed to resolve customer questions or complaints.
• Able to appropriately explain varying plan provisions to customers accurately and in a professional manner.
• Responds to telephone inquiries from insureds regarding specific claim details.
• Understands processes in entire department to assist callers with questions.
• Works closely with the claim analysts and care managers to provide a seamless customer experience.
• Outbound calls and letters to customers and providers to research incomplete claims and update the insured Plan of
Care with current providers.
• Works the Plan of Care Task List based on tasks sent from our call center team.
• Work Plan of Care email bucket daily with correspondence received both from internal and external customers.
• Escalates complaints and potential complaints appropriately.
• Documents calls in computer system.
• Completes form letters, tasks and problem solve for resolution of customer issues.
• Contributes ideas that enhance service quality.
• Works daily Metrics reports to ensure a referral is needed and complete the referral with third party vendors.
• Assist the claims payment team by reviewing and updating daily tasks.
• Performs project work and other related duties as assigned or required
Essential Functions:
• Analyze, validate and process transactions as per Desktop procedures (L3 & L4)
• Analyze and research all discrepancies
• Research & Investigate and resolve outstanding items
• Determine eligibility, entitlement and applicable plan provisions while meeting timeliness goals
• Clear and accurate written and verbal communication (Mix of scripted/unscripted) with employee, employer & stateside
resources by email and outgoing calls
• Establish action plans for each file to bring claims to resolution
• Utilize internal and external specialty resources to maximize impact on each claim file
• Use PC programs to increase productivity and performance
• Ensure that the assigned targets are met in accordance with SLA and Internal standards
• Ensure that the quality of transaction is in compliance with predefined parameters as defined by Process Excellence
• Work as a team member to meet office goals to obtain disability’s vision while demonstrating core values and
meeting key measures
• Ensure adherence to established attendance schedules
• Close visual activity - viewing a computer terminal and extensive reading
Any other essential function that may occur from time to time as directed by the Supervisor.
Primary Internal Interactions
• UM for the purpose of reporting performance, escalation handling, clarifying concerns, and seeking feedback and support
• Manager for the purpose of settling issues left unresolved by the AM and monthly evaluation of performance
• Subject Matter Expert for the purpose of work thread related issues and escalated transactions
• QCA for the purpose of feedback
• Trainers • for the purpose of training
Primary External Interactions
• Interaction with Insureds via incoming and outgoing calls information gathering/ claim queries
• Claims specialist & other Stateside Teams on emails/calls
• SME / Trainers at the client end for training
Organizational Relationships
Reports To:
AM, LTC Claims Process – Plan of Care
Supervises:
Skills
Technical Skills
• Good computer navigation skills
• Good keyboarding speed
• Good knowledge of complete MS Office suite
Process Specific Skills
• Knowledge about the Insurance industry in US
• Knowledge about US Culture
• Knowledge of Insurance principles
Soft skills (Mandatory / Desired)
Mandatory:
• Communication skills – should be able to read, interpret
business documents. Good verbal/written communication
• Proficiency in English – Spoken and Written
• Analytical and interpersonal skills
• Escalate issues if required
• Data gathering ability/ Eye for detail
• Team work/ Managing Self / Adaptability
• Ability to work successfully and perform detail-oriented work
in production driven environment
• Ability to work on routine/standardized transactions
• Ability to be flexible with regard to process changes
• Self disciplined and result oriented
• Ability to multi task
• Ability to work effectively as part of a team
Desired:
• Knowledge of Medical Terminology (preferred but not
compulsory)
Preferred:
• Claims knowledge preferred
• Knowledge of system applications preferred
Education Requirements
Graduate with at least 15 years of education.
Work Experience Requirements
- 2+ years of customer service experience