Claims Examiner Level 1

Our Story

Imagine being part of a team that’s not just shaping the future but actively driving it. At Davies North America, we’re at the forefront of innovation and excellence, blending cutting-edge technology with top-tier professional services. As a vital part of the global Davies Group, we help businesses navigate risk, optimize operations, and spearhead transformation in the insurance and regulated sectors.

What’s in Store

We are on the lookout for a Claims Examiner I to join our team. 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.

Key responsibilities include: 

• 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
• Support company values of We are Dynamic, We are Innovative, We are Connected, and We Succeed Together
• Perform other duties as assigned

This is a full-time, home-based position. 

Your Expertise, Skills, and Abilities

• High school diploma or combination of education and experience 
• Minimum of two years’ experience processing and auditing claims 
• Experience working with medical records and reviewing claims 
• Knowledge of long-term care insurance highly preferred
• Knowledge of claims processing and regulatory requirements affecting claims processing
• Possess the ability to perform responsibilities with a sense of urgency demonstrating excellent organizational, attention to detail and customer service skills
• Ability to work in a team environment with a positive attitude 
• 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 
• 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

Benefits

At Davies North America, we are dedicated to supporting the well-being and future of our qualifying employees. Our comprehensive benefits package includes:

• Medical, dental, and vision plans to ensure your health and that of your family.
• A 401k plan with employer matching to help you build a secure financial future.
• Our time-off policies, including Discretionary Time Off for exempt employees and Paid Time Off (PTO) package for non-exempt employees, reflect our commitment to promoting a healthy work environment.
• Paid holidays.
• Life insurance and both short-term and long-term disability plans, providing essential financial protection for you and your loved ones.

Diversity and Inclusion

Davies is dedicated to fostering a diverse and inclusive workplace that embraces a wide range of perspectives and experiences. We believe that diversity of thought is essential for innovation and creativity, and we actively promote an environment where all voices are valued and heard.

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