Group Life Claims Case Manager I

Position Summary

The Group Life Claims Case Manager will spend 6-8 weeks in eligibility training followed by at least 3 months of reviewing live eligibility claims while being mentored.  The Group Life Claims Case Manager then begins to build an active claim caseload while being mentored on benefit determinations.  Once the Group Life Claims Case Manager is released from mentoring, the Group Life Claims Case Manager will be subject to 5 months of audits for learning and extra training purposes.  This position utilizes problem solving, analytical, written and verbal communication skills to deliver timely and appropriate disability claim decisions while providing superior customer service to all internal and external customers.

After the training periods have ceased, this position is responsible for making all decisions on assigned claims through proactive case management according to the plan provisions, state and federal guidelines, and established protocols.  This position consults with the mentors and other team members. 

The Group Life Claims Case Manager administers claims within a variety of group sizes ranging from small (2+ lives) to large market (1000+ lives).  This position is responsible for ensuring all plan provisions are satisfied in order to make an eligibility determination.  The Group Life Case Manager consults with Group Life Case Manager III /Mentors, management, legal, and investigative resources.

You Have:

• Outstanding customer service skills
• Excellent analytical skills
• Strong math aptitude skills and PC skills (e.g., Microsoft Word & Excel)
• Ability to multi-task and meet turnaround times
• Demonstrate independent problem solving and decision-making ability
• Ability to clearly communicate claim decisions and contract language verbally and in written correspondence
• Ability to work independently and within a highly collaborative team environment
• Claim experience or product knowledge strongly preferred
• Regulatory and Compliance experience a plus
• Understanding of medical terminology helpful

You Will:

• Investigate and analyze claim information to determine coverage and benefit eligibility
• Perform accidental death investigation and draft adverse determination letter if applicable.
• Perform contestability investigation, evaluate for possible rescission, make rescission determination and draft rescission letter if applicable
• Perform dependent confinement investigation and draft adverse decision letter if applicable
• Determine Insured Earnings by reviewing payroll records, tax returns (including W2s), and partnership records and calculate payable benefits according to plan provisions within payment authority assigned by management.
• Track and record statistical data such as benefit volumes and ICD9 codes for reserves, reports and future profitability
• Prioritize and review incoming mail, correspondence and new claims to adhere to established  turn-around times
• Utilize all available resources to determine any change in claimant’s condition or work status to determine potential for gainful return to work
• Maintain imaged claim files and system notes in an orderly and systemic manner
• Calculate payable benefits according to the applicable plan provisions
• Meet quality and turnaround standards as required in the department              
• Professionally and clearly communicate claim status and decisions via telephone and in writing 
• Proactive outreach to claimants, Planholders, and physicians via telephone for information needed to determine eligibility (proof of loss, attendance/payroll, investigative reports, etc.)    
• Refer appropriate claims for review to Group Life Claims Case Manager IIIs, Team Leader,
• Adopt and support the Group Life Claims team mission and concept
• Participate in job development and growth

                            

The above description includes most significant duties performed.  However, other occasional work assignments not mentioned are assumed to be included.  Management reserves the right to assign and/or reassign duties and responsibilities at any time

Reporting Relationships

• This position reports to the Group Life Claims Team Leader, who in turn, reports to the Group Life Claims Manager.

Salary Range

$40,160.00 - $60,237.50

The salary range reflected above is a good faith estimate of base pay for the primary location of the position. The salary for this position ultimately will be determined based on the education, experience, knowledge, and abilities of the successful can