Job: STD Claim Examiner I

Jobing Description

Job Description:

PRINCIPAL OBJECTIVES:

To contribute to the overall success of Custom Disability Solutions objectives by providing timely and accurate support to our client companies and Claims department. To manage appropriate adjudication of short-term disability claims in accordance with policy provisions. To initiate and facilitate case management and other ancillary services to assure optimum outcomes.

ESSENTIAL DUTIES/RESPONSIBILITIES:

Promotes a positive customer service image through prompt, accurate and courteous responses to customer information needs.

Consistently adheres to the documented workflow guidelines and established procedures.

Maintains required levels of confidentiality.

Demonstrates competency in all modules of training program. Remains abreast of industry standards via internal/external continuing education.

Promptly and thoroughly investigates and evaluates claims within departmental and regulatory guidelines.

Interprets and administers contract provisions including, but not limited to, eligibility, covered monthly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations.

Calculates benefit and identifies other income replacement benefits. Processes financial activities, including, but not limited to, payment adjustments, stop payments, voids and check reissues, other income adjustments, reimbursement checks, and final benefits. Processes overpayments in accordance with established procedures.

Assists in the subrogation process to recover money from third parties.

Works in coordination with an LTD examiner to ensure an appropriate transition from the STD claim to LTD.

Documents claim file actions and telephone conversations appropriately.

Refers claim activity outside authority level to Supervisor/Manager for review.

Pro-actively communicates with claimants, policyholders and physicians to resolve investigations issues.

Establishes, communicates and manages claimant and policyholder expectations.

Utilizes most efficient means to obtain claim information.

Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations.

Responds to customer service issues within required timeframes.

Involves technical resources (Social Security Specialist, medical resources and vocational resources) at appropriate claim junctures.

Supports relationships with technical resources to achieve appropriate outcomes.

Meets or exceeds departmental service, quality and production objectives.

Collaborates with team members and management in identifying and implementing improvement opportunities. Informs Supervisor of any trends noted within specific client companies.

All other duties as assigned.

REQUIRED QUALIFICATIONS:

BA/BS or equivalent combination of education and experience.

Experience managing Short Term Disability claims preferred.

Knowledge of medical terminology is preferred, but not required.

Ability to fluently speak and write Spanish a plus.

Excellent customer service skills.

Excellent math and calculation skills.

Good decision making skills able to analyze complex information.

Working knowledge of Microsoft Excel and Word.