Claims Examiner

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.

Learn more about us atwww.capgemini.com.

Rightshore® is a
trademark belonging to Capgemini.

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

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

Job
Title: Claims Examiner

Location: Horsham, PA

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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 $5,000Responsible
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 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 LTC claim/case management and recertification of claim
benefitsResponsible
for Waiver of Premium (WOP) processMaintain
current knowledge of LTC 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 INSPRO and Microsoft applicationsOperate
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

Skills
& Abilities

Experience
with Microsoft Word, Excel and OutlookWillingness
to work various schedules and adapt to a changing work environmentStrong
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 analysisThe
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 standardsMaintain
knowledge of applicable company policies and procedures

QUALIFICATIONS

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.

EDUCATION
and/or EXPERIENCE

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.

LANGUAGE
SKILLS

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.

COMPETENCIES

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

MATHEMATICAL
SKILLS

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.

REASONING
ABILITY

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.

CERTIFICATES,
LICENSES, REGISTRATIONS

N/A

PHYSICAL
DEMANDS

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.

WORK
ENVIRONMENT

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.