This position is responsible for gathering and reviewing requirements for the purpose of determining initial and ongoing claimant and provider eligibility.

Responsibilities

• Assess claimant eligibility by reviewing medical records from all current providers and conducting phone assessments with the claimant or legal representative. In the event of noted inconsistencies in the claimant eligibility, coordinate a benefit eligibility assessment in order to make a final determination.
• In conjunction with plan language upon initial assessment and ongoing recertification, determine legitimacy and eligibility of service providers by requesting and reviewing provider licensing credentials, state-specific regulations, internet searches and phone assessments with the servicing provider.
• Effectively communicate, verbal and written, all aspects of the claim benefit determination process.
• Assist claimants with modifications to their current care plan, including changes in care needs as well as changes in provider.
• Monitor daily, weekly and monthly reports to ensure claims are handled timely and appropriately.
• Attend case conferences, internally and with the client, to present claims recommendations.
• Meet quality and production metrics as established and communicated by the department.
• Reviews Care Coordinator decision recommendations on tax qualified policies.
• Other duties as assigned.