Claims Manager RN & MSW

The nation's leading administrator of insurance services is looking for YOU.  This is your opportunity to join a company with a culture that promotes respect for people, integrity, learning and initiative.

 

WE ARE THE KIND OF EMPLOYER YOU DESERVE.

 

Illumifin is a leading provider of business process outsourcing for the insurance industry, managing policies for the nation's largest insurers. We also provide clients with unique risk management insight built upon our proprietary databases.

1. Reviews internal databases, client guidelines, and policy contract language to evaluate routine home and facility-based claims, in accordance with department processes and standards.
2. Communicate clearly and routinely with claimants, representatives, third parties, physicians, and other health care providers as needed.
3. Demonstrated interviewing skills which include the professional judgment to probe as necessary to uncover underlying concerns from the claimant or representative.
4. Queries service providers to obtain licensure information, proof of loss, and dates of service. Verifies that provider and/or care is appropriate base on the claimant’s diagnosis and is in accordance with contract language and government regulations regarding healthcare providers. 
5. Keeps clear and concise documentation of all claim activity within the required databases.
6. Creates plans of care and refers for review and Chronic Illness Certification as appropriate.
7. Uses time effectively to achieve expected productivity and efficiency.
8. Demonstrates ability to prioritize workload. Performs work accurately and efficiently under deadline pressures.
9. Always provides prompt, courteous and excellent customer service to internal and external customers
10. Demonstrates effective communication skills, level of attentiveness, and use of appropriate lines of authority. Promptly shares accurate and complete information to others who need it, based on HIPAA and legal documents regarding release.
11. Attends or is responsible for information provided at meetings and through other organizational channels.
12. Maintains appropriate organizational confidentiality.
13. Communicates with other team members and management on cases as needed.
14. Meets quality and production metrics as established and communicated by the department.
15. Works independently and seeks assistance as appropriate.

Qualifications

• Licensed Health Care Professional (RN or MSW)
• 4-year Degree or equivalent formal training program.
• 2 years’ experience in medical, insurance or risk management setting
• 1-year work experience in a claim processing preferred.
• Intermediate level experience with Microsoft Office products.