T4 - Lead Operations (Disability Case Manager)

Alight Solutions

12d

About The Position

The STD Claims Case Manager (CCM) is responsible for administering and case managing assigned Group Short Term Disability claims according to the plan provisions, state and federal guidelines, and established protocols. The CCM works jointly with other team members within STD, and LTD and Risk Management resources. The CCM must demonstrate the knowledge to work independently, make timely claim decisions, and must possess the knowledge and experience which allows performance of the daily activities of the job with minimal supervision. The CCM is responsible for meeting key service deliverables for turnaround times, quality assurance, and overall customer experience. This position utilizes problem solving, analytical, written and verbal communication skills to ensure timely and appropriate disability claim decisions while providing superior customer service to all internal and external customers. This position will review claims for Short Term Disability and requires consistent and effective claim management skills to succeed in a collaborative, team-oriented culture with a goal to drive positive claim outcomes.

Requirements

Excellent analytical, problem solving, and communication skills (verbal & written) essential
Minimum 2 years of disability claim management experience (STD preferred), or other previous Group insurance experience
Regulatory and Compliance experience a plus
Ability to multi-task and meet turnaround times
Ability to clearly communicate claim decisions and contract language verbally and in written correspondence
Understanding of medical terminology and medical conditions helpful
Graduate in listed discipline (BA, B.Com, BCA aggregate marks of >=55% ( No Gaps / Failure throughout Graduation)
Work Experience of 6 years +
Ability to work evening/night shifts
Minimum 2 years of disability claim management experience (STD preferred), or other previous Group insurance experience
Regulatory and Compliance experience a plus

Responsibilities

Use most efficient and effective means of proactive outreach to obtain and/or dispense information to and from claimants, departmental managers, physicians, HR, Payroll, or any other sources.
Communicate claim status and decisions via telephone and in writing.
Initiate communications to claimant, physician, and /or Plan holder to obtain information, make assessment and initial claim decision.
Proactive outreach to claimants, plan holders, and physicians via telephone for information needed for initial and ongoing claim management (e.g. tax returns, partnership records, current earnings other income benefits and medical information etc.,); notifies claimant when claim pended for missing information.
Investigate and analyse claim information to determine coverage and benefit eligibility, perform pre-existing condition investigation and draft adverse determination letter, if applicable.
Perform contestability investigation, evaluate for possible rescission and make rescission determination and draft letter if applicable.
Determine disability by comparing functionality with job description by reviewing medical information including physician statement(s) and medical records to set up claim for initial benefit approval.
Determine Insured Earnings by reviewing payroll records, tax returns (including W2s), partnership records and buy sell agreements and calculate payable benefits according to plan provisions.
Follows claim management procedures and identifies potential return to work, job accommodation opportunities when applicable.
Utilizes claim management resources, i.e. MDA (Medical Disability Advisor), and other disability guidelines, with a goal of returning claimant to active work status.
Assess claim when other sources of income are received (e.g., social security, state disability, etc.,) to ensure accurate offsets are applied and recalculate benefits as needed determining under/overpayments.
Proactively work with claimants to recover overpayments in full or negotiate monthly instalments according to established protocol.