Claims Examiner - CHCS Services, Inc

Who we are:

Wellcove, CHCS Services is a company positioned for growth and excellence. The marketplace may not be exciting, so we aim to shake things up. We are looking at acquiring more companies and have already begun to invest more in technologies and tools for our associates and customers.

Our story

We’ve been in business for over 30 years. We are a global company with delivery centers in the USA and INDIA. CHCS is an award-winning third-party insurance administrator (TPA) for senior health products. We are in the business of providing state-of-the-art administrative support services and customized care solutions to manage policies and claims. CHCS Supports some of the largest senior market insurance companies in the world. Processing hundreds of thousands of claims every year.

About you:

Are you looking for an opportunity to contribute solidly to a growing company's success by applying your tremendous organizational and analytical skills?

The ideal candidate for this role should possess a strong work ethic, excellent communication skills, critical thinking abilities, and be able to work in a fast-paced environment. You are able to work independently on set goals and complete work deadlines. A person who understands the responsibilities of working from home and is comfortable with speaking with customers on the phone. The ideal candidate is viewed as a team player and can easily be spoken of as a collaborator in past positions.

Job Summary 

As a Third-Party Administrator, CHCS Services Inc. manages eight (8) Health and Life lines of business in the Claim Department: Medicare Supplement/Select; Hospital/Indemnity; Cancer/Critical Illness; Major Medical; Life/Annuities; Long-term Term Care; Dental; Disability. 

This position is responsible for reviewing and adjudicating most levels of claims in accordance with policy, company, state, and federal guidelines for Medicare Supplement Insurance.

Supervisory Responsibilities:

 This job has no supervisory responsibilities.

 Duties/Responsibilities: 

• Responsible for accurate/timely daily review of Long-Term Care claims and policy provisions to process payment or issue denial.  

• This role does not involve full claim handling from claim receipt or intake to closure.  

• Regarding claims handling, this position is specifically limited to the payment or adjudication of invoices pertaining to long-term care claims. 

• Responsible for identifying, analyzing, and applying long-term care claim product features, including waiver of premium, waiting period, assignment of benefits, credits, and other applicable policy benefits.  Meet or exceed minimum production and quality targets as approved by management. 

• Respond accurately, timely, 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 explanations of benefits. As well as inbound claim calls.

• Maintain working knowledge of all company services pertaining to business segment, company claims, administrative and imaging software systems such as INSPRO and Microsoft applications 

• Operate within company regulations regarding HIPAA, fraud, confidentiality, and private health information guidelines.

• Other duties as assigned.

Required Skills/Abilities:

•  To perform this job successfully, the individual must be able to perform each essential duty effectively. The individual must possess advanced product knowledge, a comprehensive understanding of insurance terminology and definitions, and 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 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., CMS-1500 and UB04 forms; working knowledge of Insurance Industry and/or Healthcare. Must have typing skills of 35-45 WPM and ten-key by touch, both with a 90% accuracy rate.

• 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.  

• Must be able 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. 

  Standard Company Requirements:

• Collaborative team spirit.
• Accountable and able to work independently.
• Able to pass background screening and drug tests pre and post-hire – includes THC
• Timely responses from three professional references. 
• Verification of high school, GED, or college diploma upon request.
• Able to provide ongoing access to a smartphone for Multi-Factor Authentication and communication purposes

 Education and Experience:

 One to Two years certificate/degree from college or technical school; or 1-3 years related experience and/or training; or equivalent combination of education and experience.

 Physical Requirements:

The physical demands described here are representative of those that an employee must meet to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these functions.

While performing the duties of this job, the employee is regularly required to sit. The employee frequently uses 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 the ability to adjust focus.