Senior Associate - LTC Claims


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.

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Location: Pensacola, FL

skills and responsibilities:



Job Description

Title: Claim Examiner I

Department: Claims


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.

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 AND RESPONSIBILITIES include the following. Other duties may be

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 files


job has no supervisory responsibilities.


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.

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.


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


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.


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


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.


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


ICA and/or LOMA certifications preferred.


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.

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.


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.

environment is in office. The noise
level in the work environment is usually low to moderate.