Job Summary

Makes timely, accurate, and customer-focused Long-Term Disability claim decisions. Proactively engages clinical, vocational, employer, financial, and other informational internal and external sources to gather relevant data, and compares it to the applicable contract/administrative agreement and procedural documents. Conducts an analysis of data and engages peers and management as appropriate. Communicates verbally and in writing an accurate and comprehensive decision. Maintains performance at or above departmental metrics.

Principal Duties & Responsibilities

Makes timely, accurate, and customer-focused Long-Term Disability new and ongoing claim decisions on moderately complex to highly complex claims using advanced independent discretion guided by company procedures and regulatory standards; handles the most complex claims from a clinical and financial perspective; reaches out to obtain relevant clinical, vocational, employer, financial, and other information; compares the information to the terms, limitations, and conditions of the contract/administrative services agreement and applicable procedural documents and renders the claim decision as quickly as possible

Documents the claims system in an accurate and comprehensive manner; prepares, updates, and utilizes a claim management plan to attain the most appropriate outcome; remains in full compliance with regulatory requirements; demonstrates an above average level of proficiency in product and claims administration techniques; remains fully compliant with operational standards; meets or exceeds claim team operational metrics

Maintains a superior level of genuine caring and empathetic customer service throughout all interactions; takes appropriate actions to earn the claimants and employers trust and confidence; anticipates customer's needs and takes action as appropriate

Works with internal partners to support flexibility, collaboration, creating a positive work environment, consistently maintaining professionalism and integrity, actively taking steps to foster high morale, and demonstrating a dedication to excellence

Mentors and coaches new team members and participates in projects supporting the teams business initiatives

Performs other duties as required

Education & Experience Required

High School Diploma
7 years of LTD industry claims experience
Demonstrated proficiency in product specific areas of STD, LTD or AM as well as federal and state regulations governing these products and services

Education & Experience Preferred

Bachelors Degree In business, healthcare, or a related field
Masters Degree In business
2+ years of Supervisory, Managerial, and/or leadership experience
Utilization Review Experience and/or experience using specific medical and/or behavioral health criteria or protocols
4 or more years of experience in disability management industry managing claims

Or an equivalent combination of education and experience

Job Knowledge & Skills

Strong understanding of disability claim management concepts

Solid understanding of medical terminology/pathology/anatomy

Ability to verbally articulate clearly, concisely and explain complex situations

Superior writing skills

Confident with independent decision making

Ability to consistently meet deadlines

Proven ability to work with confidential information

Moderate skills with Microsoft Office and other software applications

High level of customer service skills/phone skills

Strong ability to multi-task and prioritize