Associate - Claims Support

About Capgemini

With more than 180,000 people in over 40 countries,
Capgemini is a global leader in consulting, technology and outsourcing
services. The Group reported 2015 global revenues of EUR 11.9 billion. 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 Experience™, and draws on Rightshore®,
its worldwide delivery model.

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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:

Job Location: Horsham Township, PA

CHCS Services

Job Description

Job Title: Claim Examiner I

Department: Claims


As a Third Party
Administrator, CHCS Services Inc. manages eight (8) Health and Life lines of
business in the Claim Department; Medicare Supplement/Select;
Hospital/Indemnity; Cancer/Critical Illness; Major Medical; Life/Annuities;
Long Term Care; Dental; Disability.

This position is
responsible for the review and adjudication of most levels of claims in
accordance with policy, company, state, and federal guidelines for 1– 4
insurance product lines.

RESPONSIBILITIESinclude the following. Other duties may be assigned.

Responsible for
accurate/timely daily review of claims and policy provisions to determine
appropriate claim eligibility assessments for payment or denial up to authority
limit of $20,000.00Responsible 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 benefitsProvide Excellent
Customer Service to all external and internal stakeholdersResponsible for initial
telephonic claim intake/interview with claimant or documented representative to
determine claim benefit needsReview and work
applicable reports and documents pertaining to claims eligibility determination
and ongoing claim benefitsResponsible 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
adjudicationRespond 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 benefitsResponsible for any
on-going claim/case management and recertification of claim benefitsResponsible for working
closely with all claim vendors/resources such as Clients, Care Managers,
Medical Consultants, Independent Medical Examiners or other vendors utilized in
the claim adjudication processMaintain current
knowledge of federal, state, and insurance regulations and requirementsMaintain working knowledge
of all company and services pertaining to business segmentMaintain working
knowledge and proficiency in company claims, administrative and imaging
software systems such as AS400, CAPSIL, INSPRO, Visiflow, Global and Microsoft
applicationsMaintain client and
company quality and production standardsMaintain knowledge of
applicable company policies and proceduresOperate within company
regulations regarding HIPAA, fraud, confidentiality, and private health
information guidelinesInteract professionally
with other business units to gather and analyze data needed to properly
adjudicate claims and documentation of claims files


This job has no
supervisory responsibilities.


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.

Claim Examiner I 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. CMS-1500 and UB04 forms; working knowledge
of Insurance Industry and/or Healthcare. Must have typing skills of 35-45 WPM
and ten-key by touch both with 90% accuracy rate.


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


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,
commissions, proportions, percentages, area, circumference, and volume.


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.


certifications preferred.


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. The employee must regularly lift
and/or move up to 10 pounds. 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.