030296-Claims Examiner

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Responsible for accurate/timely daily review of Long Term Care claims and policy provisions to determine appropriate claim eligibility assessments for payment or denial up to authority limit of $5,000

• Responsible for accurate/timely determination of additional benefits applicable under policy provisions such as Wavier of Premium, Inflation Protection Options, Guaranteed Purchase Options, and other applicable rider/policy benefits

• Provide Excellent Customer Service to all external and internal stakeholders

• Responsible for timely request and follow-up request of any/all required additional information, i.e. medical records/notes, appropriate forms/documents, statements and/or certificates needed for proper claim adjudication

• Respond accurately, timely and professionally to all oral and written external and/or internal correspondences received from stakeholders in regard to benefits, eligibility, claim payments, denials and/or explanation of benefits

• Responsible for any on-going LTC claim/case management and recertification of claim benefits

• Responsible for Waiver of Premium (WOP) process

• Maintain current knowledge of LTC federal, state, and insurance regulations and requirements

• Maintain working knowledge of all company and services pertaining to business segment

• Maintain working knowledge and proficiency in company claims, administrative and imaging software systems such as INSPRO and Microsoft applications

• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines

• Interact professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files

 Skills & Abilities:

·Experience with Microsoft Word, Excel and Outlook

· Willingness to work various schedules and adapt to a changing work environment

·  Strong communication skills – verbal and written.

·  Ability to disseminate and learn information in a short period of time. 

·  Efficient and accurate use of technology for data entry, documentation, and analysis

·  The ability to multi-task and quickly navigate multiple business tools while maintaining quality.

· Proven ability to meet deadlines.

· Ability to make a positive contribution as demonstrated by learning new skills and making suggestions for process/procedure improvement.

• Maintain client and company quality and production standards

• Maintain knowledge of applicable company policies and procedures


To perform this job successfully, the individual must be able to perform each essential duty effectively.  The individual must possess advance product knowledge, comprehensive understanding of insurance terminology and definitions, core knowledge of company and department processes and procedures related to the ability to complete job responsibilities /duties in a proficient and professional manner. 

 Must have knowledge of medical terminology, ability to read and interpret most medical records/notes, ICD-9/10 and CPT/HCPC/CDT coding; Familiarity with different medical claim forms, i.e. HCFA-1500 and UB04 forms; working knowledge of Insurance Industry and/or Healthcare.


One to Two years certificate/degree from college or technical school; or 2-5 years related experience and/or training; or equivalent combination of education and experience.


Must have the ability to read and interpret documents such as policies and operating and procedural manuals; Ability to write routine correspondence; Ability to speak effectively to customers, clients or employees of the organization. 


Critical Thinking; Customer Service; Work Standards; Decision-Making; Communication; Interpersonal Skills; Integrity/Honesty and Adaptability/Flexibility


Must have the ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals; Ability to calculate figures and amounts such as discounts, interest, and percentages.


Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form;  Ability to deal with problems involving several concrete variables in standardized situations.




The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit.  The employee frequently is required to use hands to finger, handle, or feel.  The employee is occasionally required to reach with hands and arms and talk or hear.  Specific vision abilities required by this job include close vision, and ability to adjust focus.


The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work environment is in office.  The noise level in the work environment is usually low to moderate. 

Responsible for chasing outstanding invoices from customers of our clients. Plays a vital role in the cash-flow of our client ensuring credit given to customers is monitored and controlled effectively

Assists customers experiencing repayment difficulties, chase up late payments and arrange with the customer the best way forward to repay the debt. 
As a member of the team, participates in meeting service levels, key measurement targets of the team and delivers a high quality and cost effective service. Is proactive in ensuring the delivery of a customer focused service to client.  Proficient knowledge of one or more processes.
General Responsibilities / Accountabilities:
• Manages an AR portfolio. Responsible for achieving cash collection and ageing targets.
• Negotiates, implements and documents payment solutions with customers
• Builds and maintains strong relationships with external customers
• Escalates disputes and protracted nonpayment situations in accordance with engagement policies
• Identifies frequently recurring situations at customer level, escalates such situations and suggests remedial actions
• Applies fundamental collection techniques and adjusts collection strategies to the requirement of the portfolio
• Maintains knowledge of the  business area of the client that is supported 
• Ensures control and compliance regulations are followed
• Issues and monitors automatic and manual reminders to customers 
• Performs customer account reconciliations
• Processes used:
• B2C4.1.2 Collect From Tier 2 Customer (Medium Risk, Standard)
• B2C4.1.3 Collect From Tier 3 Customer (Low Risk, Small)
• B2C4.1.4 Retained Collection
• B2C4.1.5 Escalate unpaid amounts
• B2C4.1.6 Perform Dunning
• B2C4.1.7 Create and send statement
• B2C4.2.1 Refer to 3rd Party Collection
• B2C4.2.3 Agree Settlement/Payment Plan
• B2C4.2.5 Process Write Off
• +D4B2C7.2.1 Produce Ad-Hoc Report
• B2C8.1.1 Archive Documents
• B2C8.2.1 Retrieve Archived Document
• B2C8.3.1 Destroy Archived Document
Qualifications: Bachelor’s degree
Role Specific Competencies:
• Should be proficient in BPO Process and Analytics
• Should have progressing skills in BPO Technology 
• Should have baseline skills in Commercial Control
About Capgemini

With more than 190,000 people, Capgemini is present in over 40 countries and celebrates its 50th Anniversary year in 2017. A global leader in consulting, technology and outsourcing services, the
Group reported 2016 global revenues of EUR 12.5 billion (about $13.8 billion USD at 2016 average rate). Together with its clients, Capgemini creates and delivers business, technology and digital
solutions that fit their needs, enabling them to achieve innovation and competitiveness. A deeply multicultural organization, Capgemini has developed its own way of working, the Collaborative Business ExperienceTM, and draws on Rightshore®, its worldwide delivery model.

Learn more about us at www.capgemini.com.
Capgemini is an Equal Opportunity Employer encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, national origin, gender identity/expression, age, religion, disability, sexual orientation, genetics, veteran status, marital status or any other characteristic protected by law.

This is a general description of the Duties, Responsibilities and Qualifications required for this position. Physical, mental, sensory or environmental demands may be referenced in an attempt to communicate the manner in which this position traditionally is performed. Whenever necessary to provide individuals with disabilities an equal employment opportunity, Capgemini will consider reasonable accommodations that might involve varying job requirements and/or changing the way this job is performed, provided that such accommodations do not pose an undue hardship.

Click the following link for more information on your rights as an Applicant -http://www.capgemini.com/resources/equal-employment-opportunity-is-the-law