Claims Examiner Sr.- Absence Management Specialist

Quanterix • South Portland, ME

103d • $56,120 - $70,160 • Hybrid

About The Position

The Claims Examiner Sr. - Absence Management Specialist is accountable for utilizing independent judgment and discretion in the decision making process for determining eligibility under federal, state laws and client policy. Secure and analyze information to make and approve decisions on all short term disability, insured or self-insured, and/or statutory claims and their concurrent leave claims. Develop and apply appropriate claim and workflow management strategies, coordinating both disability and leave decisions while meeting timeliness regulations.

Requirements

• High School Diploma and at least three to five years of claims experience required.
• Bachelor's degree preferred.
• In-depth knowledge of federal and state laws pertaining to leaves of absence.
• Basic knowledge of ERISA.
• Knowledge of medical terminology required.
• Professional written and verbal communication and interpersonal skills.
• Strong reading, writing, and arithmetic skills required.
• Ability to gather, analyze and organize data to make educated decisions.
• Ability to identify critical issues and exercise independent judgment.
• Demonstrates ability to independently investigate, evaluate and adjudicate claims of high complexity.
• Demonstrates ability to assist with claim denial reviews and approval of worksheets.
• Demonstrates ability to assist in claim auditing.
• Completion of Mentor Training and successful completion of one year of mentoring.
• Proficient in the use of Microsoft programs; Excel and Word.
• Typing proficiency at 45 wpm.
• Experience using web-based programs.
• Demonstrates prioritization and organizational skills.
• Ability to meet deadlines while balancing competing demands.
• Critical thinking and analytical skills.

Nice To Haves

• Excellent math, verbal and business writing skills.
• Good reading comprehension.
• Ability to organize work, manage time and follow through.
• Proven experience in providing internal and external customer service.
• Ability to handle confidential information with the utmost judgment and discretion.

Responsibilities

• Responds to customer service issues within required timeframes.
• Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements.
• Manages multiple lines of business including disability, leave of absence, and Voluntary.
• Determines eligibility under federal and state requirements for leaves submitted and determines eligibility under client's plan/policy.
• Reviews and manages medical certification supplied by the healthcare provider.
• Makes determinations to approve or delay claims and reaches out to additional resources for review.
• Has independent authority to approve disability claims up to a specified dollar amount.
• Reviews and approves claim denial decisions for lower-level claims examiners.
• Determines the duration associated with the leave and/or disability based on healthcare provider information.
• Communicates approvals, denials, leave extensions, return to work plans, and other important information regarding the leave to the employee and client.
• Manages leaves that are concurrent with Short Term Disability and Workers' Compensation.
• Processes all leaves within specific timeframes outlined within Matrix Best Practices guidelines.
• Facilitates issue resolution and collaborates with internal partners as needed.
• Interprets and administers policy/plan provisions.
• Investigates all relevant issues, providers, payments, or denials in compliance with departmental procedures.
• Manages self-insured business in accordance with clients' plans and custom requirements.
• Calculates earnings and benefit levels accurately and consistently.
• Documents claim file actions and conversations thoroughly.
• Collaborates with team members and management to identify and implement improvement opportunities.
• Participates in finalist presentations and ongoing client meetings.
• Reviews audit findings and prepares rebuttals.
• Assists supervisor during periods of extended absences or vacations.
• Provides support and manages additional tasks for team members as needed.
• Conducts audits of lower-level claim examiner's work and provides coaching, feedback, and support.
• Mentors new hire claim examiners.

Benefits

• An annual performance bonus for all team members.
• Generous 401(k) company match that is immediately vested.
• A choice of three medical plans (including prescription drug coverage).
• Company contribution to Health Savings Account for High Deductible Health Plan enrollees.
• Multiple options for dental and vision coverage.
• Company provided Life & Disability Insurance.
• Family friendly benefits including Paid Parental Leave & Adoption Assistance.
• Hybrid work arrangements for eligible roles.
• Tuition Reimbursement and Continuing Professional Education.
• Paid Time Off - new hires start with at least 20 days of PTO per year.
• Volunteer days, community partnerships, and Employee Assistance Program.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Transit and Ground Passenger Transportation
• Education Level: High school or GED