Claim Manager I - Clinician (Remote)

Job Description

Job Description

Description

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 Claim Manager I - Clinician (CMC) to join our team. As the Claim Manager Clinician, you must be a Registered Professional Nurse or Licensed Social Worker (who has Long-Term Care experience) who will be responsible for managing a daily caseload of Long-Term Care (LTC) Claims. Using established claim policies and guidelines, the CMC evaluates claims to determine whether the Insured is benefit qualified and receiving covered services from an eligible provider. The CMC also educates policyholders on their coverage and communicates directly with service providers and physicians to facilitate claim resolution.

Key Responsibilities

• Interpret LTC policy coverage using claims guidelines and policy language to assess eligibility.
• Evaluate provider qualifications and covered services
• Accurately input and maintain complete data, documentation, and notes in the claims administrative system
• Monitor aging of assigned tasks to ensure compliance with established turnaround time
• Serve as the point of contact for claimants and/or their representatives, ensuring a positive and supportive experience
• Contribute to process improvement initiatives by helping develop enhanced customer service strategies
• Stay current on relevant state/territory regulations, industry trends, and emerging issues
• Consult with claimants’ physicians and/or providers as needed to gather supporting medical information
• Conduct phone evaluations to monitor claimants’ progress and assess changes in care needs
• Identify and escalate claims requiring special handling, including proposed denials, potential fraud, or coordination of benefits with other payers
• Review and summarize medical records to support claim evaluations
• Assess complex medical claims upon request from non-clinical team members, providing clinical insight and guidance
• Review claim filles and complete Chronically Ill Certifications in accordance with policy requirements and regulatory standards
• 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, remote position.

Skills, knowledge & expertise

• Professional designation required: Minimum of Registered Nurse (RN) or Licensed Social Worker (LSW with Long-Term Care experience)
• Experience in LTC, disability, or related claims is highly preferred
• Minimum of 2 years claims experience is preferred
• Strong knowledge of claims processes and/or LTC insurance industry and practices
• Solid understanding of medical terminology
• Excellent verbal, written and presentation skills, with the ability to communicate effectively across all corporate levels, as well as with providers, policyholders and their representatives
• Strong analytical and problem-solving skills, with ability to manage and prioritize multiple claims and assigned projects
• Demonstrated ability to exercise independent judgment and make sound business decisions that support the merits of claims
• Proficiency in Microsoft Office Products and other business-related software
• Ability to quickly learn and adapt to new system applications
• Flexible and adaptable to change in a dynamic work environment

Benefits

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.