Senior Associate - Claims Examiner


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

Rightshore® is a trademark belonging to

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:

Location: Pensacola, FL

CHCS Services

Job Description

Job Title:
Claim Examiner I – Level 2-3

Department: Claims

Reports To:


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.

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, Care Management System 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


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 1-3 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


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.


AHIP, ICA and/or LOMA 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.