Team Lead - 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.
Learn more about us atwww.capgemini.com.
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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
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
Title: Long Term Care Eligibility
Location: Horsham PA
DUTIES AND RESPONSIBILITIES include the following. Other duties may be
for determining initial and ongoing eligibility for Long Term Care claimantsDetermines
which assessment/reassessment tools should be utilized to assess claimant
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 adjudicationResponsible
for any on-going LTC claim/case management and recertification of claim
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
current knowledge of LTC federal, state, and insurance regulations and
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
written and verbal communication skills a mustAbility to
work and adapt to change in a fast-paced environmentManages
assigned caseload of claimants
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
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
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.
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
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.
Thinking; Customer Service; Work Standards; Decision-Making; Communication;
Interpersonal Skills; Integrity/Honesty and Adaptability/Flexibility
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.
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
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. Specific vision abilities
required by this job include close vision, and ability to adjust focus.
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.