051830-Claims Examiner – Healthcare

About Capgemini

Capgemini is a global leader in consulting, digital transformation, technology and engineering  services. The Group is at the forefront of innovation to address the entire breadth of clients’ opportunities in the evolving world of cloud, digital and platforms. Building on its strong 50-year+ heritage and deep industry-specific expertise, Capgemini enables organizations to realize their business ambitions through an array of services from strategy to operations. Capgemini is driven by the conviction that the business value of technology comes from and through people. Today, it is a multicultural company of 270,000 team members in almost 50 countries. With Altran, the Group reported 2019 combined revenues of €17billion.
Visit us at www.capgemini.com. People matter, results count


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

Understand LTC; review of a claim in it’s entirety (i.e. medical, facility records), being able to make an intelligent decision, review Appeals of date of eligibility, maneuver through our systems using tasks, requesting medical / facility records; being able to respond to call documents.

Profile: Claim Examiner


• Responsible for accurate/timely daily review of Long Term Care claims and policy provisions to determine appropriate claim adjudication
• Provide Excellent Customer Service to all external and internal stakeholders
• Responsible for timely request and follow-up request of any/all required additional information, i.e. provide licensure, appropriate forms/documents, statements and/or certificates needed for proper claim adjudication
• Responsible for accurate, timely and professional oral and written external and/or internal correspondences   
• Responsible for meeting daily / weekly / monthly productivity goals
• Maintain current knowledge of LTC federal, state, and insurance regulations and requirements
• Maintain working knowledge of all company requirements pertaining to business segment
• Maintain working knowledge and proficiency of all standard operating procedures regarding claims administration according to the policy contracts
• Interact with client and demonstrate in-depth claim job knowledge
• Maintain a working knowledge or all applications: administration and imaging software systems, such as Citron, Case 360, INSPRO and Microsoft Applications
• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines
• Interact professionally with other business units to gather and analyze data needed to properly determine appropriate claim adjudication

Skills & Abilities:

• Experience with Microsoft Word, Excel and Outlook
• Willingness to work various schedules and adapt to a changing fast paced work environment
• Strong communication skills – verbal and written
• Ability to disseminate and learn information in a short period of time 
• Efficient and accurate use of technology for data entry, documentation, and analysis
• The 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 standards

• Maintain 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 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.


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. 


The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. 


Candidates should be flexible / willing to work across this delivery landscape which includes and not limited to Agile Applications Development, Support and Deployment.



Posted on:

February 10, 2021

Experience level:

Experienced (Non Manager)

Education level:

Bachelor's Degree (±16 years)

Contract type: