STD Claims Examiner Team Lead

Reliance Matrix

2d•$63,540 - $85,800•Hybrid

About The Position

Responsible for supporting both the supervisor and examiners in the day-to-day operation of the claim team. The Claims Team Lead will also be responsible for developing and sustaining excellent internal partnerships with other areas in the company. In addition, the Claims Team Lead will act as an examiner when needed to balance workloads. In this role, they would be accountable for 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

Associate’s Degree or equivalent required.
Minimum of 5 years relevant experience
Demonstrated ability to handle multiple competing priorities.
Demonstrated ability to provide feedback on Claims handling
Demonstrated ability to function with limited supervision.
Demonstrated ability to work well in a high visibility environment, with excellent written and verbal communication skills.
Ability to Travel: Up to 10%
Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand.
Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading.
Employee is required to have hearing sufficient to understand verbal instruction and answer telephones.

Nice To Haves

Bachelor’s Degree preferred.
Completion of HIAA, LOMA or ICA courses desirable.

Responsibilities

Supports the achievement of established departmental goals and objectives related to all claim operations in compliance with the Claim Organization’s standards
Supports both the supervisor for team leadership, as well as the individual examiners to provide day-to-day guidance and workload balancing.
Partners with Claim Operations leaders to review specific claims that fall within defined parameters to better understand claim trends, training opportunities, coaching opportunities, and/or performance management opportunities.
Supports all training and coaching activities through communications via phone, email and video follow-up with examiners/supervisors.
Develops and maintains strong working relationships with business partners.
Reviews claims to ensure that decisions related to eligibility, disability, offsets, benefit calculations and ongoing claim management are accurate and appropriate.
Ensures achievement of specific customer service, quality and production objectives.
Ensures claim process consistency through continuous communication and feedback with the examiners/supervisor.
Responsible for assisting in reviewing and completing monthly reports
Ability to interact and respond to both internal and external customers regarding claim results.
Ability to prioritize and manage changing workloads, meeting deadlines independently and through management of others.
Ability and knowledge to assist with claim denial reviews.
Ability to assist in claim auditing.
Completion of Mentor Training and successful completion of one year of mentoring.
Collaborates with team members and management in identify and implementing improvement opportunities.
Ability to participate in finalist presentations and ongoing client meetings.
Ability to review audit findings and prepare rebuttals.
Ability to back up supervisor in periods of extended absences or vacations
Ability to back up examiners in periods of high volume or extended absences/vacations with the following duties and responsibilities:
Responds to customer service issues within required timeframes.
Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements.
Determining eligibility under federal and state requirements for leaves submitted and determines eligibility under client’s plan/policy.
Medical certification review and management supplied by the healthcare provider.
Makes determinations to approve, deny or delay and or reach out to additional resources for review.
Determining the duration associated with the leave and or disability based on the information given by the healthcare provider.
Communicating approvals, denials, leave extensions, return to work plans and other important information regarding the leave to the employee and client.
Managing leaves that are concurrent with Short Term Disability and Workers’ Compensation.
Managing intermittent, continuous and client specific leaves of absences.
Processing all leaves within the specific timeframes outlined within Matrix Best Practices guidelines.
Facilitate issue resolution and draw on expertise of internal partners as needed.
Ability to interpret and administer policy/plan provisions
Fully Investigates all relevant issues, providers, payment or denials, promptly and in full compliance with departmental procedures and unfair claims practice and regulations.
Manages self-insured business in accordance with client’s plans and custom requirements.
Basic knowledge of ERISA.
Ability to calculate earnings and benefit levels.
Document claim file actions and conversations thoroughly.
Fully Investigates all relevant issues, providers, payments.
Demonstrates ability to independently investigate, evaluate and adjudicate claims of high degree of complexity.
Any other job-related duty as deemed appropriate by management

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