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Job Details

LTD Claims Examiner Sr.

Hawthorne, NY, United States

Posted on
Jun 26, 2020

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Job Description:nJob Information Obtains and analyzes information to make claim decisions and payments on LTD, Voluntary disability and WOP claims. The goal of the position/role is to consistently render appropriate claim determinations based on a review of all available information and the terms and provisions of the applicable policy. * Reviews and investigates disability claims by using telephone and written contact with the applicable parties, (claimant, employer/supervisor, credit union, treating physician, etc.) to gather pertinent data to analyze the claim. * Adjudicates claims accurately and fairly in accordance with the contract, appropriate claim policies and procedures, and state and federal regulations, meeting productivity and quality standards based on product line. * Utilizes appropriate medical and risk resources, adhering to referral polices, and transferring claims to the appropriate risk level in a timely manner. * Conducts in-depth pre-existing condition or contestable investigations if applicable. * Calculates benefit payments, which may include partial disability benefits, integration with other income sources, survivor benefits, residual disability benefits, etc. * Develops and maintains on-line claim data (and paper file if applicable). * Provide customer service that is respectful, prompt, concise, and accurate in an environment with competing demands. Analysis and Adjudication * Fully investigates and adjudicates a large volume complex claims, does not review simple claims. * Identifies and investigates change in Total Disability definition (any occ). * Independently reviews and manage claims with high degree of complexity within the $3,000 per month approval authority limit. * Independently makes the determination if a policyholder with life policy up to $200,000 is eligible for a waiver of premium. * May handle the claim administration for sensitive or complicated policyholders. * Majority of work is not subject to supervisor review and approval. Case Management * Consistently manage assigned case load of 60-80 complex cases independently. * Collaborates with team members and management in recommending and implementing improvement opportunities. Miscellaneous * Seen as subject matter expert within team and provides mentor or training support for newer Examiners to assist in their development or on claims related projects. * Assists management in pre-sale presentations, problem/complaint investigation and resolution. * Assists management in responding to Insurance Department inquiries and executive complaints. * Identify trends or training needs of the team. Requirements * High School Diploma or GED. Associates degree in Business, Finance, Social Work, or Human Resources preferred. Level I LOMA designation preferred. * Minimum of 5 years experience processing long term disability claims. * Advanced understanding of claim management techniques and critical thinking in activities requiring analysis and/or investigation. * Experience working in confidential/protected identification environments. * Thorough knowledge of medical terminology. * Excellent math and calculation skills. * Proven ability to work well in a high-visibility, public-oriented environment. **MEMBERS ONLY**SIGN UP NOW***. Insurance Company is an equal opportunity employer. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, veteran status or any other consideration made unlawful by applicable federal state or local laws.n}

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