LTC Claims Pending Specialist

(October 2025 Start Date- 6 Roles Are Available) – Remote USA.

Employees in Southeastern WI are eligible for fully remote work after a successful completion of training (approximately six months). The required on-site training days are Mondays and Tuesdays (Franklin, WI).
This role will start in early October 2025, and the recruitment process will be approximately 2-6 weeks from application.

Primary Duties and Responsibilities

Determines the applicability of benefits claimed by interpreting contract provisions, state regulations, and uses claim knowledge in interpreting and analyzing facts to reach claim decisions on new and continuing claims, consistent with Northwestern Long Term Care’s claim philosophy.
Orders and reviews appropriate medical, investigative, service provider, and other information needed to determine the eligibility of long-term care claims including reimbursement of eligible expenses.
Conduct interviews to gather pertinent claim information from the insured or their representative.
Answer incoming calls from the field and insureds or their representatives to explain claims status, hypothetical claim situations, and contract provisions.
Communicate effectively verbally and in writing with Insureds and their representatives, Field Force, medical practitioners, and related service providers, attorneys, other insurance companies, and divisional resources, is involves negotiation and conflict resolution.
Preserves Northwestern Long Term Care’s image and reputation in the approval or denial of benefits despite difficult and delicate circumstances.
May be called upon for project and committee work as a Subject Matter Expert (SME), including the development of process improvements.
Work cohesively with team members to meet the goals of the team and division.
Qualifications
Registered Nurse or Social Work license preferred
Healthcare background OR minimum 3+ years of long-term care insurance experience highly desirable
A bachelor’s degree or equivalent combination of education and work experience will be considered
Experience with insurance claims is desirable
Strong written and verbal communication skills required
Strong technology skills required
Ability to analyze medical records and draw out necessary information for claims processing
Demonstrates initiative and strong support of team goals and results
High degree of analytical skills, personal organization, and time management
Strong client focus and customer service skills
Ability to manage ambiguity and maintain a positive outlook in the face of change
Ability to identify process improvement opportunities.