054069-Quality Review Representative – Healthcare Claims  

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
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.

Job Title:     Quality Review Representative  
Department:     Process Control Unit

  • May also apply directly by sending your resume to Paige Perillard at paige.perillard@capgemini.com

This job performs quality review for the LTC Insurance operational and claim environment by primarily reviewing processed transactions for accuracy.  This includes, but is not limited, to the following essential duties and responsibilities:
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.  Other duties may be assigned.
•    Review all policy and claim level transactions against the standard operating procedures
•    Responsible for reviewing benefit eligibility determinations to ensure that the claim recommendations meet the contractual obligations of the policy
•    Assign and document all mechanical and financial errors as discovered
•    Maintains a strong working knowledge base of all long term care products and services.
•    Maintain production and quality standards established in the department
•    Participate and support policy review decisions in the appeal process
•    Monthly reporting to all engagement managers and supervisory staff on the quality results of their department and staff
•    Participate in client level meetings.  Create action plans as agreed upon with the client and meet all timelines and deliverables
•    Complying with company regulations regarding HIPAA, confidentiality, and private health information.
•    Ability and Flexibility to work overtime as required. 

This job has no supervisory responsibilities.


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.


Two years of College Preferred. Minimum Requirements: High school diploma or general education degree (GED); or two years related experience and/or training; or equivalent combination of education and experience.


Need the ability to read and comprehend simple instructions, short correspondence, and memos.  Candidate should have the ability to write simple correspondence with minimal errors.  Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.


•    In-depth insurance knowledge.  Focus on Long Term Care Insurance and Benefit Eligibility determinations a plus
•    Promote an exceptional level of excellence and pride in Customer Service
•    Integrity/Honesty
•    Sound interpersonal and communication skills
•    Motivation
•    Ability to multi-task
•    Meticulous attention to detail 
•    Ability to lead others through performance and professionalism
•    Ability to work in a fast paced environment
•    Highly developed problem solving skills
•    Organizational/Planning/Organizing


Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.


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.


Proficiency in basic computer applications is required. (MS Word, MS Excel)


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 and talk or hear.  The employee is occasionally required to stand and walk.  Specific vision abilities required by this job include close vision.


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.

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:

June 28, 2021

Experience level:

Experienced (Non Manager)

Education level:

Bachelor's Degree (±16 years)

Contract type:


Business units:

BUSSERV (us-en)