Senior Associate - Long Term Care Eligibility 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.

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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:

Work Location: Horsham, PA

Desired skills and responsibilities:

Job Title: Long Term Care
Eligibility Examiner

Location: Horsham PA

duties may be assigned.

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

Responsible for any on-going LTC claim/case management and
recertification of claim benefitsReviews assessment tools including medical information, face to
face assessments, Physician Questionnaires and other documents to determine
claimant eligibility given the policy's eligibility criteriaEvaluates whether additional information, medical review,
managerial review and/or SIU involvement is necessaryMonitors ongoing eligibility, appropriateness of care and
existence of any red flags and address/resolves them as appropriateDetermines claim eligibilitywhile providing excellent customer
service to all internal and external stakeholdersMaintains current knowledge of LTC federal, state, and insurance
regulations and requirementsOperates within company regulations regarding HIPAA, fraud,
confidentiality, and private health information guidelinesInteracts professionally with other business units to gather and
analyze data needed to properly adjudicate claims and documentation of claims
filesDetermines if provider of care/services satisfies policy and state
requirementsDetermines if care/services are consistent with Plan of CareEvaluates whether care/services are consistent with previous
information pertaining to functional/cognitive capacityReview eligibility, date of eligibility, and claims appeals in
accordance with SOPLTC experience preferredStrong written and verbal communication skills a mustAbility to work and adapt to change in a fast-paced environmentManages assigned caseload of claimants

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. Excellent decision making skills needed for determinations made on
a timely basisEfficient 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


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


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


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.