To analyze reported claims, determine benefits due and make timely payments and adjustments; to medically manage disability claims; to coordinate investigative efforts and to thoroughly review contested claims; to evaluate and arrange appropriate referral of claims to outside vendors; and to negotiate settlement of claims up to the designated authority level.
- Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan.
- Determines benefits due, makes timely claims payments and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
- Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.
- Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.
- Informs claimants of documentation required to process claims, required time frames, payment information and claims status either by phone, written correspondence and/or claims system.
- Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
- Evaluates and arranges appropriate referral of claims to outside vendors for surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
- Refers cases as appropriate to supervisor and management.
- Negotiates settlement of claims up to designated authority level.
- Maintains professional client relationships
- Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
- LICENSING: At least one of the following licenses is required: RN, LVN, CRC, COHN, CVE, LPC or LCSW.
- Three (3) years benefits or disability claims management experience required.
- Excellent oral and written communication, including presentation skills
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Ability to work in a team environment
- Excellent negotiation skills
- Ability to meet or exceed Performance Competencies
- Baccalaureate degree from an accredited college or university in nursing, social work or vocational rehabilitation is preferred.