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LTD Claim Examiner II

Hawthorne, NY, United States

Posted on
Jun 29, 2020

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Job Description:nJob Information The Claim Examiner II obtains and analyzes information to make claim decisions and payments on Long Term Disability LTD and Waiver of Premium 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. Duties and Responsibilities: * 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, cost of living adjustments, 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 simple to complex claims. * Identifies and investigates change in Total Disability definition (any occ). * Independently reviews and manage claims with high degree of complexity within the $1,500 per month approval authority limit. * Independently makes the determination if a policyholder with life policy up to $125,000 is eligible for a waiver of premium. * Majority of work is not subject to supervisor review and approval. Case Management * Independently manages assigned case load as outlined in LTD Key Measures * Collaborates with team members and management in identifying and implementing improvement opportunities. Miscellaneous * Remains current with all corporate and disability management practices. * Collaborates with team members and management in identifying and implementing improvement opportunities. * Collaborates with management on claims with high degree of complexity. * Any other job-related duty as deemed appropriate by management. Required Knowledge, Skills, Abilities, Competencies, and/or Related Experience: *or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience* * High School Diploma or GED. Associates degree in Business, Finance, Social Work, or Human Resources preferred. Level I LOMA designation preferred. * 2 years experience processing long term disability claims. * Demonstrated understanding of claim management techniques and critical thinking in activities requiring analysis and/or investigation. * Experience working in confidential/protected identification environments. * Knowledge of medical terminology. * Good math and calculation skills. * Proven ability to work well in a high-visibility, public-oriented environment. Required Competencies * Customer Service: Promptly acknowledges customers' needs, both internal and external. Ensures customers' needs are handled in a timely and appropriate manner. Creates a positive impression. * Communication/Relationship Skills: Demonstrates effective interpersonal and listening skills: takes direction, practices active listening, accepts feedback. Communicate/respond appropriately to varied audiences/tasks. Exhibits teamwork, honors commitments. * Problem Solving/Decision Making: Anticipates, analyzes and defines problems. Develops and assesses alternative solutions as necessary. Makes appropriate decisions in a timely manner. Analyzes impact of decisions. * Productivity: Work is accomplished quickly and accurately. Takes responsibility for actions. Prioritizes work effectively and uses time efficiently. Accomplishes goals and objectives. * Dependability: Makes/fulfills commitments. Consistently works independently, meets deadlines, and accepts responsibility for his/her actions. Adheres to all attendance requirements. Prompt, well prepared and ready to contribute. **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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