STD Claims Examiner II

Reliance Matrix•South Portland, ME

1d•$23 - $29•Hybrid

About The Position

Obtains and analyzes information to make claim decisions and payments of Short Term Disability (STD) claims. The goal of the position/role is to consistently pay the accurate amount for each claim in accordance with the contract. Research Applies knowledge of disability products, policies and contracts. Interprets and applies contract/policy definitions of disability and relevant provisions, clauses, exclusions, riders and waivers as well as statutory requirements. Utilizes reference materials and tools regarding medical, vocational and disability issues to identify and evaluate claim information in a fair and objective manner. Efficient use of applicable disability claims system(s). Applies routine medical and technical claims skills, 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. Determine and implement appropriate return to work strategy for assigned cases. Applies contract specifics regarding eligibility and pre-existing formulas in reference to specific claim. Communicates with claimants, policyholders, and physicians to resolve investigations concerns. Comfortably makes balanced decisions in situations where there are potential adverse consequences. Case Management Utilizes appropriate intervention for the characteristics of each claim. Manages assigned case load of 100-110 complex and some simple cases independently. Collaborates with team members and management in identifying and implementing improvement opportunities. Manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities. Consistently remain within workflow guidelines on diaries and casework & adjust desk management if needed. Provides clear, concise and accurate information to claimants as well as the claims administrative system. Serves as a subject matter expert within team, provides some mentor support for newer examiners to assist in their development. Customer Service 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. Reliance Matrix delivers employee benefits, absence management and workforce productivity solutions through the financial stability of a top-rated insurance carrier, the agility and innovative spirit of a Third Party Administrator (TPA), and the daily commitment of thousands of team members across America. Where larger competitors offer size, we inspire confidence and long term engagement through integration, reliability and dedication to providing customized solutions. Reliance Matrix innovates and provides technology-driven absence and benefit solutions that enable employees and employers to manage time away from work. We help employers attract and retain valuable human capital through thoughtful, inclusive benefit programs delivered with care. We bring top-tier regulatory knowledge and cutting edge technology to help optimize workforce productivity and compliance. We offer a seamless member experience customized to each individual’s need and event. We integrate our solutions and expertise with leading HR technologies to ensure accuracy, efficiency and a superior customer experience. We are a proud member of the global Tokio Marine Group, one of the oldest, largest and most respected insurance organizations in the world. In the business hierarchy, human capital is the most precious of assets. Reliance Matrix delivers comprehensive, integrated solutions and services to attract, protect and help optimize an employer’s work force in a changing, challenging world.

Requirements

2 years STD claims examiner experience (Short Term Disability)
Associates Degree, Bachelors Preferred
Promptly acknowledges customers' needs, both internal and external.
Ensures customers' needs are handled in a timely and appropriate manner.
Creates a positive impression.
Demonstrates effective interpersonal and listening skills: takes direction, practices active listening, accepts feedback.
Communicate/respond appropriately to varied audiences/tasks.
Exhibits teamwork, honors commitments.
Anticipates, analyzes and defines problems.
Develops and assesses alternative solutions as necessary.
Makes appropriate decisions in a timely manner.
Analyzes impact of decisions.
Work is accomplished quickly and accurately.
Takes responsibility for actions.
Prioritizes work effectively and uses time efficiently.
Accomplishes goals and objectives.
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.

Nice To Haves

Level I LOMA Designation Preferred

Responsibilities

Obtains and analyzes information to make claim decisions and payments of Short Term Disability (STD) claims.
Applies knowledge of disability products, policies and contracts.
Interprets and applies contract/policy definitions of disability and relevant provisions, clauses, exclusions, riders and waivers as well as statutory requirements.
Utilizes reference materials and tools regarding medical, vocational and disability issues to identify and evaluate claim information in a fair and objective manner.
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.
Determine and implement appropriate return to work strategy for assigned cases.
Applies contract specifics regarding eligibility and pre-existing formulas in reference to specific claim.
Communicates with claimants, policyholders, and physicians to resolve investigations concerns.
Utilizes appropriate intervention for the characteristics of each claim.
Manages assigned case load of 100-110 complex and some simple cases independently.
Collaborates with team members and management in identifying and implementing improvement opportunities.
Manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities.
Consistently remain within workflow guidelines on diaries and casework & adjust desk management if needed.
Provides clear, concise and accurate information to claimants as well as the claims administrative system.
Serves as a subject matter expert within team, provides some mentor support for newer examiners to assist in their development.
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.

Benefits

An annual performance bonus for all team members
Generous 401(k) company match that is immediately vested
A choice of three medical plans (that include prescription drug coverage) to suit your unique needs.
For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
Multiple options for dental and vision coverage
Company provided Life & Disability Insurance to ensure financial protection when you need it most
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 in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service.
Volunteer days, community partnerships, and Employee Assistance Program
Ability to connect with colleagues around the country through our Employee Resource Group program