STD/Absence Claims Case Manager I

Guardian Life Insurance•Work From Home - PA, PA

3d•$41,880 - $62,820•Remote

About The Position

The STD/Absence Claims Case Manager I (CM) is responsible for adjudicating and medically managing Short Term and Absence claims involving specific diagnoses or leave types that tend to resolve quickly. The CM will work with employers, employees, and health care providers to administer Short Term disability in conjunction with other paid or unpaid leaves covered by Guardian, including Family and Medical Leave Act (FMLA), State Paid Medical Leave, and/or State Paid Disability. The CM will manage the claim according to the plan provisions, state and federal guidelines, and established protocols. This role requires sound judgment, critical thinking, and problem-solving skills to work independently, interpret contract provisions, analyze medical and claim information, and administer benefits through the appropriate claim duration or return to work. The CM is responsible for meeting key service deliverables such as turnaround times, quality assurance, and overall customer experience. This position utilizes analytical reasoning, problem solving, adaptability, and strong written and verbal communication skills to ensure timely and appropriate absence and disability claim decisions while providing superior customer service to all internal and external customers. This position requires consistent and effective claim management skills, resilience in a fast-paced environment, and the ability to adapt as claim circumstances, priorities, or information change.

Requirements

Bachelor’s degree preferred
Strong math aptitude, including the ability to calculate benefits and review payroll or income information accurately
Demonstrated ability to use critical thinking, problem solving, and sound judgment to evaluate information and determine appropriate next steps.
Ability to prioritize and multi-task while navigating through multiple business applications, adapting to changing priorities, and remaining resilient in a fast-paced environment.
Ability to work independently within established procedures while providing exceptional customer service through clear and professional communication
Successful completion of a job-related assessment is required.

Nice To Haves

Group Benefits experience.
Short Term Disability, Statutory Paid Leave, Family Medical Leave, adjacent insurance industry experience, regulatory and compliance or other professional equivalent experience.
Strong skillset in Microsoft Windows applications, including Microsoft Word, Excel, and Outlook; AI/Copilot prompting skills

Responsibilities

Effectively understand contract language and plan design for group disability
Communicate claim status and decisions via telephone and in writing
Initiate communications to claimant, physician, and planholder to assess and facilitate job accommodation opportunities
Proactive outreaches to claimants, planholders, and physicians via telephone for information needed for initial and ongoing claim management (e.g. current earnings, other income benefits, medical information, etc.); notifies claimants when claims are pended for missing information
Proactively identify claim issues, develop and execute a well-reasoned plan of action for pending and ongoing disability claims, and adjust strategies as new information becomes available. Utilize, manage, and direct appropriate resources to support timely and accurate benefit determination for internal and external customers in accordance with policy provisions, regulatory requirements, internal standards, and customer service expectations.
Apply critical thinking to investigate, analyze, and synthesize claim information, contract provisions, medical documentation, and regulatory requirements to determine coverage, benefit eligibility, and appropriate claim outcomes.
Demonstrate adaptability and resilience by effectively managing shifting priorities, changing claim circumstances, and time-sensitive decisions in a fast-paced environment.
Determine if claimants meet the definition of disability as defined in the contract by reviewing occupational requirements, analyzing medical information, identifying gaps or inconsistencies, and applying sound judgment to reach appropriate claim decisions.
Review, validate, and refine AI-generated claim recommendations, data extractions, and draft correspondence, applying professional judgment before finalizing decisions or communications.
Verify the accuracy and completeness of AI-assembled claim files and AI-flagged discrepancies, ensuring quality, regulatory compliance, and audit-readiness of claim documentation.
Establish, document and execute claim action plan and recommended path including return to active work at claimant’s own job
Determine Insured Earnings by reviewing payroll information from the planholder and calculate payable benefits according to plan provisions, with strong attention to accuracy, detail, and applicable offsets.
Follow all claim management procedures and facilitate potential return to work and job accommodation opportunities when applicable
Utilize claim management resources such as MDA (Medical Disability Guidelines) and other disability tools to assist with appropriate durational disability
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, to determine under/overpayments. Proactively work with claimants to recover overpayments in full or negotiate monthly installments according to established protocols
Assess claim for restrictions and limitations to establish appropriate partnership with PRT
Remain composed, resourceful, and solutions-oriented when resolving routine claim challenges, addressing missing information, and determining appropriate next steps.