Team Lead - Operations - Eligibility 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.

Click the following link for more
information on your rights as an Applicant:

Location: Pensacola, FL

CHCS Services

Job Description

Job Title:
Claim Examiner II – Level 2

Department: Claims

Reports To:


As a Third Party Administrator, CHCS Services Inc. manages eight
(8) lines of business in the Claim Department; Medicare Supplement/Select;
Hospital/Indemnity; Cancer/Specified Disease; 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 4–6 insurance product lines.

duties may be assigned.

Responsible for accurate/timely daily review of claims and policy
provisions to determine appropriate claim payment or denial up to authority
limit of $30,000.00Responsible 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 benefits.Review and work other applicable reports and documents pertaining
to claims eligibility determinationResponsible for interpreting policy provisions to accurately
determine claim benefits in accordance with policy benefitsResponsible for timely request and follow-up request of any/all required additional information, i.e.
medical records, appropriate forms, statements and certificates needed for
proper claim adjudicationRespond appropriately 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
benefitsMaintain 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 and
administrative software systems such as AS400, CAPSIL, 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 informationInteract 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 II must have knowledge of medical terminology,
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.


Two years certificate/degree from college or technical school; or
4-7 years related experience and/or training; or equivalent combination of
education and experience.


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


Critical Thinking; Customer Service; Work Standards;
Decision-Making; Communication; Interpersonal Skills and


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 detailed
but uninvolved written or oral instructions.
Ability to deal with problems involving a few 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.

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