CLAIMS EXAMINER LEVEL 1

About Us

With a multinational global team, Davies Group is a specialist professional services and technology firm working in partnership with leading insurance, highly regulated, and global businesses.

At Davies Group, we help clients to manage risk, operate core business processes, and to transform and grow. We deliver operations, consulting and technology solutions across the risk and insurance value chain, including excellence in claims, underwriting, distribution, regulation, customer experience, human capital, transformation, and change management.

In 2020, Davies North America acquired TriPlus Services Inc., and later in 2021, acquired Disability Management Services Inc., both third party companies that provide a range of insurance services to clients. These acquisitions, now known as Davies Life and Health, have allowed the Davies Group to become leaders within the insurance industry, sharing their knowledge and expertise regarding claims, policy administration, actuarial services, consulting services, and management solutions to help meet the needs of their clients.

Are you looking for a company that is Dynamic and Innovative where the employees are Connected and Succeed Together? If so, Davies may just be the right choice for you.

Job Overview

Davies Life and Health is looking for a Claims Examiner I to join their Claim Payment department. As the Claims Examiner I, you will be responsible for processing ongoing long-term care insurance claims which involves reviewing and analyzing all correspondence received from policyholders, policyholder representatives, and providers of long-term care services to ensure accuracy, completeness, and continued eligibility. This role will process claim payments in accordance with contract language and plan of care approved by the Claim Manager utilizing CAPS claim processing system and On-Base imaging system. This position will report to the Team Manager of the Claim Payment department.

To be successful in this role, you must possess strong analytical, communication, problem-solving and interpersonal skills. You will be required to work both individually and collaboratively with teammates to fulfill objectives and make recommendations to improve processes. You must be highly organized, pay strong attention to detail and handle sensitive information in a confidential manner. This is a full-time, remote position that requires participation in 4-6 weeks of remote mandatory training upon hire.

Responsibilities and Duties

• Process ongoing long-term care insurance claims for either facility or non-facility processing only
• Review long-term care invoices, Monthly Verification Forms, caregiver logs and/or Statement of Care forms, and all other claims documentation received to determine continued eligibility and proper payment amount
• Determine whether documentation substantiates that the policyholder continues to meet the level of care and services contained in the policy and approved by the Claim Manager
• Recognize and refer possible plan of care changes to Claim Management Department based on established Department business rules
• Accurately document policyholder accounts and correspondence in accordance with established Department processes and procedures.
• Identify and refer possible fraud cases for further investigation
• Process and document all required diary entries in the CAPS system
• Maintain compliance with all applicable laws and regulations
• Meet or exceed all regulatory requirements for processing claims submitted for payment including prompt-pay regulations
• Process payments in accordance with federal and state laws and Medicare/Medicaid regulations that affect the management and administration of claims
• Handle confidential information abiding by HIPAA privacy laws
• Meet or exceed all established minimum expectations/metrics and goals for the position
• Meet or exceed standards for Productivity and Quality as established for the role
• Practice excellent oral and written skills to communicate with policyholders or their representatives, and providers by telephone and in writing, as well as with internal co-workers
• Maintain adherence to all Claim Payment Department processes and procedures
• Additional duties as assigned

Experience and Qualifications

Required

• High school diploma/GED required

Preferred

• College degree or equivalent industry-related work experience preferred
• Minimum of two years’ experience processing and auditing claims preferred
• Experience working with medical records and reviewing claims preferred
• Knowledge of long-term care insurance highly preferred

Knowledge, Skills, and Abilities

• Knowledge of claims processing and regulatory requirements affecting claims processing
• Strong analytical skills, organizational and attention to detail
• Possess the ability to perform responsibilities with a sense of urgency demonstrating excellent organizational and customer service skills
• Ability to work in a team environment with a positive attitude and participate in making recommendations or suggestions to management for improving processes or procedures which will positively affect the productivity and efficiency of the Department
• Possess excellent oral/written communication, interpersonal, analytical, and problem-solving skills
• Knowledge and ability to utilize existing software products including, but not limited to, MS Office products; ability to learn new systems and upgrades in technology utilized by the Company
• Ability to learn and relay knowledge of products offered by the Company
• Ability to read and interpret complex policy contract language and correspondence including knowledge of Medicare forms and medical terminology

Essential Requirements

• Must have US work rights
• Must speak English
• Local to the US
• High school diploma/GED required

Other Duties

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the individual for this job. Activities, duties or responsibilities may change at any time with or without notice.

Position Type, Work Environment, and Physical Demands

This is a full time, fully home-based, hourly, non-exempt position. This role predominantly operates from a professional home-based office environment routinely using standard office equipment such as computers, phones, printers, photocopiers, and scanners and requires prolonged periods of sitting at a desk while working on a computer. While performing the duties of this job, the individual will be required to regularly hear and talk. This is a largely sedentary role requiring the ability to sit at a desk, reach outward, use a phone, have use of fingers to operate office equipment such as a keyboard, mouse, phone, printer, copier, and to reach above the head, bend, or stand as necessary.

Diversity and Inclusion

Davies is committed to being a diverse and inclusive workplace. We welcome candidates of all genders, gender identity and expression, neurodiversity, sexual orientation, disability, physical appearance, body size, race, age, nationality, and belief (or lack thereof).

Rewards and Recognition

We embrace innovation and run an annual competition available for all teammates to submit their ideas. The top 10 finalists travel to the current year’s competition site where they pitch their ideas to our investors. The winner receives funding to bring their idea to life and the runners up receive a reward for their involvement. Some of our teammates have moved across into brand new positions to further develop their ideas/projects!

Benefits

• Medical, dental, and vision plans
• 401k plan with employer matching
• Paid Time Off, Sick Leave, and Paid Holidays
• Life insurance, short term, and long-term disability plans
• Amazing Executive and Senior leadership as well as fabulous teammates