Claim Manager Clinician (Remote)
$79,976–$89,960 year
Remote · United States
Job Summary
Manage Long Term Care (LTC) claims in a remote office as a Claim Manager Clinician (CMC). Evaluate LTC policy eligibility, interpret policy language, assess provider qualifications and covered services, input and maintain data in claims systems, and monitor turnaround times. Educate claimants and representatives on coverage and claim processes, coordinate with physicians/providers to gather supporting information, and communicate about policy benefits. Conduct clinical reviews of medical records, perform telephonic evaluations to track changes in care needs, identify cases requiring special handling (including potential denials or fraud), and assist with Chronically Ill Certifications in line with policy requirements. Maintain current knowledge of state/territory regulations and industry trends; contribute to process improvements and provide guidance to non-clinical team members. Requires RN or LSW designation, with preferred LTC Claims experience and strong analytical, communication, and Microsoft Office skills. This is a full-time, remote role with responsibilities spanning claims evaluation, education, data management, and clinical support.
Required Qualifications
- Professional designation RN or Licensed Social Worker (LSW)
- Minimum of 2 years claims experience (preferred) in LTC, disability, or related claims
- Strong knowledge of claims processes and LTC insurance industry practices
- Proficiency in medical terminology and Microsoft Office
- Ability to communicate effectively with providers, claimants and stakeholders
- Ability to perform telephonic evaluations and clinical reviews
- Ability to manage multiple claims and adapt to a dynamic environment
Desired Qualifications
- Registered Nurse (RN) or Licensed Social Worker designation
- 2+ years of claims experience (LTC or related)
- Strong knowledge of claims processes and LTC insurance practices
- Proficiency in Microsoft Office
- Excellent verbal and written communication
- Ability to work in a remote environment
- Clinical review and medical-records evaluation experience
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