LTD Claims Examiner I
Posted on May 18, 2019 by Reliance Standard
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 pay the accurate amount for each claim in accordance with the contract.
Develop an understanding and working knowledge of disability products, policies and contracts.
Develop an understanding of the applicable contract/policy definitions of disability and relevant provisions, clauses, exclusions, riders and waivers as well as statutory requirements.
Become familiar with reference materials and tools regarding medical, vocational and disability issues.
Develop an operating knowledge of the applicable disability claims system(s).
Develop basic medical and technical claims skills and an understanding of claim practices and procedures.
Utilizes most efficient means to obtain claim information.
Analysis and Adjudication
Fully investigates all relevant claim issues.
Provides payment or denials promptly and in full compliance with department procedures and regulations.
Involves technical resources (Social Security specialist, medical resources, and vocational resources) at appropriate claim junctures.
Researches contract specifics regarding eligibility and pre-existing formulas in reference to specific claim.
Pro-actively communicates with claimants, policyholders, and physicians to resolve investigations issues.
Utilizes appropriate intervention for the characteristics of each claim.
Manages assigned case load of 60-80 simple and some complex cases with oversight from Sr. Examiner or supervisor.
Partners with supervisor or Sr. Examiners to develop desk management capabilities and priorities to ensure all claims commitments are met in the timeframe expected.
Provide customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.
Establishes, communicates, and manages claimant and policyholder expectations.
Documents claim file actions and telephone conversations appropriately.
Collaborates with team members and management in identifying and implementing improvement opportunities.
Required Knowledge, Skills, Abilities, Competencies, and/or Related Experience:
Associate Degree (AS/AA), Bachelors Preferred
Business, Finance, Social Work, Human Resources or related
0-2 years of related experience
Work experience in decision-making and information analysis.
Demonstrated prioritization and organization skills.
Experience working in confidential/protected identification environments.
Good math and calculation skills.