030298-Claims Eligibility Examiner

  • Responsible for determining initial and ongoing eligibility for Long Term Care claimants
  • Determines which assessment/reassessment tools should be utilized to assess claimant eligibility.
  • 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
  • Responsible for any on-going LTC claim/case management and recertification of claim benefits
  • Reviews assessment tools including medical information, face to face assessments, Physician Questionnaires and other documents to determine claimant eligibility given the policy's eligibility criteria
  • Evaluates whether additional information, medical review, managerial review and/or SIU involvement is necessary
  • Monitors ongoing eligibility, appropriateness of care and existence of any red flags and address/resolves them as appropriate
  • Determines claim eligibility while providing excellent customer service to all internal and external stakeholders
  • Maintains current knowledge of LTC federal, state, and insurance regulations and requirements
  • Operates within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines
  • Interacts professionally with other business units to gather and analyze data needed to properly adjudicate claims and documentation of claims files
  • Determines if provider of care/services satisfies policy and state requirements
  • Determines if care/services are consistent with Plan of Care
  • Evaluates whether care/services are consistent with previous information pertaining to functional/cognitive capacity
  • Review eligibility, date of eligibility, and claims appeals in accordance with SOP
  • LTC experience preferred
  • Strong written and verbal communication skills a must
  • Ability to work and adapt to change in a fast-paced environment
  • Manages assigned caseload of claimants

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. 

·         Excellent decision making skills needed for determinations made on a timely basis

·         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.  

 Problem identification and resolution of accounts payable invoices and payment of invoices.
As a member of the team, participates in meeting service levels, key measurement targets of the team, delivers a high quality and cost effective service and oversees the process (or part of process) and customer service decisions. Can take leadership to ensure the delivery of a customer focused service to client with highly proficient knowledge of one or more processes and continually strives to improve the process
General Responsibilities / Accountabilities:
Is responsible for processing transactions and producing outputs in the following areas:  
• Receive and Scan Documents
• Perform Invoice Pre-Process-Manual
• Perform Pre-Process-Electronic
• Perform E-invoicing (EIPP)
• Capture
• Process PO Invoices
• Process Non-PO Invoices
• Process ERS Invoices
• Archive and Retrieve Documents
Perform Pre-Process Claim
Process Claim Processing
Process Manual Payments
Process Electronic Payments
Qualifications:  Bachelor’s degree
Role Specific Competencies: 
• Should have progressing skills BPO Technology, Commercial Control and Analytics
• Should be proficient in BPO Processes. 

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