Claims - Claims Examiner

Long-Term Care Claims Examiner

The Long-Term Care (LTC) Claims Examiner is responsible for the accurate and timely adjudication of long-term care insurance claims. This role ensures compliance with policy provisions, regulatory requirements, and company standards while delivering a high level of customer service to policyholders, providers, and internal stakeholders.

Responsibilities include:

• Review, evaluate, and adjudicate Long Term Care claims in accordance with policy provisions and established guidelines
• Analyze claim documentation including invoices, care plans, and provider credentials
• Apply knowledge of Coordination of Benefits (COB), Medicare, Medicaid, and other payer sources when applicable
• Ensure claims are processed within established turnaround times and service level agreements (SLAs)
• Communicate effectively with policyholders, providers, and internal teams regarding claim status, requirements, and determinations
• Identify and request additional documentation when necessary to support claim decisions
• Maintain accurate and detailed claim notes in system of record
• Ensure compliance with HIPAA and all applicable regulatory and privacy requirements
• Participate in quality assurance activities and implement feedback for continuous improvement
• Support training and mentoring of new or junior staff as needed

Required Qualifications:

• High school diploma or equivalent required; associate or bachelor's degree preferred
• 2+ years of experience in insurance claims, healthcare administration, or Long-Term Care claims processing
• Strong understanding of Long-Term Care policies, benefits, and eligibility criteria preferred
• Knowledge of medical terminology and healthcare documentation
• Proficiency in claims systems and Microsoft Office (Excel, Word, Outlook)
• Strong analytical and decision-making skills
• Excellent written and verbal communication skills
• Ability to manage multiple priorities in a fast-paced environment

Core Competencies:

• Attention to Detail
• Critical Thinking & Problem Solving
• Customer Focus
• Time Management & Productivity
• Compliance & Risk Awareness
• Team Collaboration

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.