Claim Manager, Clinician

MDD Forensic Accountants

Claim Manager Clinician managing Long Term Care claims using established policies and guidelines. Assessing eligibility and educating policyholders on coverage in a fast-paced remote environment.

Posted 6/12/2026full-timeRemote • Alabama • 🇺🇸 United StatesJuniorMid-Level💰 $38 - $43 per hourWebsite

About the role

Key responsibilities & impact

Determine eligibility of LTC claims to individualized policy
Interpret LTC policy coverage using claims guidelines and policy language to assess eligibility.
Evaluate provider qualifications and covered services.
Accurately input and maintain complete data, documentation, and notes in the claims administrative system.
Monitor the aging of assigned tasks to ensure compliance with established turnaround time standards.
Educates claimants and their representatives on policy coverage and claim processes
Serve as the point of contact for claimants and/or their representatives, ensuring a positive and supportive experience.
Contribute to process improvement initiatives by helping develop enhanced customer service strategies.
Stay current on relevant state/territory regulations, industry trends, and emerging issues.
Investigate and analyze medical evidence to determine whether policy benefit qualifier(s) are met.
Consult with claimants’ physicians and/or providers as needed to gather supporting medical information.
Conduct telephonic evaluations to monitor claimants’ progress and assess changes in care needs over time.
Identify and escalate claims requiring special handling, including proposed denials, potential fraud, or coordination of benefits with other payers.
Clinical Review Responsibilities
Review and summarize medical records to support claim evaluations.
Assess complex medical claims upon request from non-clinical team members, providing clinical insight and guidance.
Review claim files and complete Chronically Ill Certifications in accordance with policy requirements and regulatory standards.

Requirements

What you’ll need

Professional designation required: Registered Nurse (RN) or Licensed Social Worker (LSW)
Experience in LTC, disability, or related claims is preferred
Minimum of 2 years claims experience is preferred
Strong knowledge of claims processes and/or LTC insurance industry and practices
Solid understanding of medical terminology
Excellent verbal, written and presentation skills, with the ability to communicate effectively across all corporate levels, as well as with providers, policyholders and their representatives
Strong analytical and problem-solving skills, with ability to manage and prioritize multiple claims and assigned projects
Demonstrated ability to exercise independent judgment and make sound business decisions that support the merits of claims
Proficiency in Microsoft Office Products and other business-related software
Ability to quickly learn and adapt to new system applications
Flexible and adaptable to change in a dynamic work environment

Benefits

Comp & perks

Medical, dental, and vision plans to support your health and that of your family
A 401(k) plan with employer matching
Time‑off policies, including Discretionary Time Off (DTO) for exempt employees and Paid Time Off (PTO) for non‑exempt employees
Paid holidays
Life insurance and short‑term and long‑term disability coverage
Paid sick leave, paid family and parental leave, and other mandated benefits in accordance with applicable state and local requirements

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims processingLTC insurancemedical terminologyclinical reviewdata documentationtelephonic evaluationsclaims analysisprovider qualifications evaluationmedical evidence investigationChronically Ill Certifications

Soft Skills

communication skillsanalytical skillsproblem-solving skillsindependent judgmentproject managementcustomer serviceadaptabilityflexibilitypresentation skillsinterpersonal skills

Certifications

Registered Nurse (RN)Licensed Social Worker (LSW)