Claims - Care Manager, RN, Claims

Who We Are Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs.

Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.

We are seeking an experienced Registered Nurse (RN) to serve as a Care Manager supporting Long Term Care (LTC) insurance claims. This individual contributor role is responsible for conducting comprehensive clinical eligibility reviews to determine whether policyholders meet the benefit eligibility requirements outlined in their LTC policy. The Care Manager, RN will complete and document Chronically Ill Certifications (CICs) and develop Plans of Care (POCs) for initial claims and ongoing recertifications, ensuring determinations are clinically sound, and policy aligned.

Key Responsibilities

• Perform detailed clinical reviews of LTC claim files to determine eligibility in accordance with policy provisions and regulatory requirements.

• Assess Activities of Daily Living (ADLs), cognitive impairment, diagnoses, comorbidities, and level of care needs.

• Review medical records, Minimum Data Set (MDS) assessments, facility documentation, home health records, daily visit notes, and supporting claim forms.

• Determine whether the insured meets the policy definition of Chronically Ill.

• Prepare and document Chronically Ill Certifications (CICs) and individualized Plans of Care (POCs) for initial approvals and recertifications.

• Clearly document clinical rationale to support benefit determinations.

• Collaborate with Claims, Eligibility, and Customer Service teams to obtain additional documentation when necessary.

• Maintain knowledge of LTC policy language, benefit triggers, and regulatory requirements.

Qualifications

• Active, unrestricted Registered Nurse (RN) license required.

• Clinical experience in long-term care, home health, geriatrics, case management, or utilization review preferred.

• Experience reviewing medical records and assessing functional and cognitive impairment.

• Knowledge of LTC insurance benefit triggers, ADL requirements, and chronically ill certification standards preferred.

• Strong clinical judgment, critical thinking, and documentation skills.

• Ability to manage multiple cases and meet turnaround expectations.

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.

Originally posted on Himalayas