Job Description Summary
Transamerica has been helping people feel better about the future for more than 100 years, and we're proud of the trust we've earned. But we believe our responsibility goes beyond insurance, investments, and retirement accounts. We're also in the business of helping people improve their financial and personal well-being, so they can add more years to their lives, and more life to their years.
- Evaluate and determine benefit eligibility for claimant and provider for Long Term Care benefits (including Nursing Home, Assisted Living, Home Health Care, Therapeutic device, Home Modifications, Medical Alert, Alternate Plans of Care, etc.)
- Obtain proof of loss documents (including assessments, plan of care, medical records, state licensing information) from claimant and provider, analyze information against the policy contract and make an independent benefit determination using professional judgment.
- Evaluation of more complex levels of claims including contestable claim investigations, facility evaluations, negotiation of Alternate Plans of care, complaint or escalation claims.
- Investigate various state regulations/licensing and determines applicable coverage available under the policy contract. Consult and correspond with state regulatory agencies and providers regarding the level of care provided.
- Investigate coverage for Long Term Care Benefits, including complex Notice of Claim calls (contestable, timely filing, Alternate Plans of Care) and review of level of care/provider changes.
- Evaluate Alternate Plan of Care provisions and formulate a binding agreement to the claimant. Negotiate agreement if applicable.
- Accept or deny liability based on independent evaluation of assessments, plans of care, medical records, state regulations, state licensure requirements, and contract provisions.
- Explain policy coverage, claims status, claim determination to claimant through verbal and written communication.
- Document claims record with determination (clinical information, insured's eligibility, provider's eligibility, benefit approved, assessment synopsis, direction to other departments).
- Consult with external vendors.
- Provides chronically ill certifications as required by the IRS federal guidelines.
- Represent the Company by participating in depositions.
- Other duties as assigned based on divisional needs.
- Complies with and abides by all regulations, policies, work procedures, instruction, and all safety rules.
- Bachelor's degree or licensure as a Licensed Vocational Nurse (LVN/LPN), Registered Nurse, or Social Worker or equivalent work experience.
- 3-5 year's experience working in a long term care insurance eligibility/determination role
- Mastery of the Claims Eligibility Specialist function
- Ability to read and interpret a policy contract and communicate that information to our claimants in a manner which is easy to understand.
- Detail oriented with sound investigative skills.
- Ability to handle multiple claim investigations on the same case at one time.
- Ability to communicate clearly and effectively both verbally and in writing.
- Ability to handle customers in a calm, professional, friendly & patient manner.
- Ability to work independently and utilize professional judgement to make accurate determinations and manage caseload.
- Ability to quickly adapt to changes either within the department or during the daily work assignments.
- Excellent organizational and time management skills.
- Ability to work in a team environment and display a positive attitude in an effort to meet department goals.
- Ability to work within a Windows Operating system and related programs.
- Moderate proficiency working with Microsoft Office Products.
- Professional medical background, e.g. Nurse (LVN, RN), Physical Therapist (PT), Occupational Therapist (OT), Licensed Social Worker (LBSW/LMSW), or Certified Case Manager (CCM)
- This is a full-time remote position.
Why Work for Us
Total Rewards at Transamerica: It's more than a paycheck.
Our comprehensive Total Rewards package is designed to help support you in many ways — throughout all stages of your life and career. We provide a competitive, market-driven program that encompasses base compensation, bonus potential, retirement, health and wellness benefits, learning and development opportunities, plus great employee perks. All designed with you in mind… to help you live your best life, grow personally and professionally - and feel valued for the work you do.
Learn more about our Total Rewards Package.
Equal Opportunity Employer:
Transamerica Life Insurance Company is an Equal Employment Opportunity employer and does not discriminate against any applicant or employee because of age, religion, sex, gender identity, genetic information, race, color, national origin, pregnancy, sexual orientation, marital status, participation in the uniformed services (e.g. U.S. Armed Forces, National Guard), physical or mental disability, or any other status protected by federal, state, or local equal employment opportunities laws.
Applicants with physical or mental disabilities may be entitled to a form of reasonable accommodation under the Americans with Disabilities Act and certain state and local laws. A reasonable accommodation is a change in the way things are normally done which will insure equal employment opportunity without imposing undue hardship on the Transamerica Companies. Please contact: firstname.lastname@example.org if you are a job seeker with a disability, or are assisting someone with a disability, and require assistance to apply for one of our jobs.
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