Senior Team Lead - Eligibility Specialist

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 at http://www.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

Job
Location: Pensacola, FL

CHCS

Job
Description

Job
Title: Eligibility
Specialist – Team Lead

Department: LTC Claims

SUMMARY

This
position is responsible for overall management of the Eligibility Specialists
for Kanawha, State of Alaska and WEA including monitoring claim decisions,
managing work load, training and providing feedback to Management.

ESSENTIAL
DUTIES AND RESPONSIBILITIES include the following.

1. Responsible for reviewing Benefit
Eligibility Assessments to determine if decisions are accurate and timely.

2. Responsible for reviewing and interpreting
policy provisions to ensure a new claimant as eligible for benefits under
policy provisions.

3. Responsible for obtaining and reviewing
Claim Forms, Plans of Treatment, Tax Qualified Addendums, Attestations,
Facility Evaluations, Admission Records and Doctor’s orders to determine level
of care is appropriate and in accordance with policy provisions.

4. Communicate with Client in regard to out of
contract provisions and/or state regulations that result in modifications to
policy benefits.

5. Review Complaints, Appeals and DOI
complaints as it pertains to Eligibility Decisions.

6. Knowledge of Contestabilty guidelines by
product to ensure review is conducted in a timely manner.

7. Monitoring follow-up memos on a weekly basis
to ensure staff is meeting internal departmental goals.

8. Assisting Intake / Support Team /
Eligibility Specialist as needed.

9. Participate in preparing files and
responding to Third Party Audits.

10
Maintain current knowledge of federal, state and local insurance regulations
and requirements.

11.
Respond to escalations from policyholder’s, Power-of-Attorneys, and Agencies in
regard to claim eligibility decisions.

12.
Manage inventory for Intake / Claim Support and Eligibility Specialist.

13.
Responsible for reviewing YCA to validate benefits and ensure time-line of
events surrounding claims eligibility process.

14. Interact with other business units to gather
and analyze data needed to properly access eligibility and document claims
files.

QUALIFICATIONS

To
perform this job successfully, an individual must be able to perform each
essential duty satisfactorily. The requirements listed below are representative
of the knowledge, skill, and/or ability required. Reasonable accommodations may
be made to enable individuals with disabilities to perform the essential
functions.

EDUCATION
and/or EXPERIENCE

High
School diploma or equivalent.
Detailed-oriented with excellent organizational skills.

LANGUAGE
SKILLS

Ability
to read, write and comprehend English.
Ability to respond to inquiries or complaints from customers, agencies,
or members of the business community.
Ability to effectively present information to Management.

MATHEMATICAL
SKILLS

Ability
to apply mathematical concepts in order to effectively calculate claim
payments.

REASONING
ABILITY

Ability
to define problems, collect data, establish facts, and draw valid conclusions.

CERTIFICATES,
LICENSES, REGISTRATIONS

None

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 frequently required to sit;
use hands to finger, handle, or feel; and talk or hear. The employee is occasionally required to
stand; walk; reach with hands and arms; climb or balance; and stoop, kneel,
crouch, or crawl. The employee must
occasionally lift and/or move up to 10 pounds.
Specific vision abilities required by this job include close vision,
distance vision, color 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. The noise level in the work environment is
usually moderate.