Job Responsibilities and Requirements

KEY RESPONSIBILITIES

*other duties as assigned*

Primary responsibilities are to serve as the liaison between Claimant and Claims Examiner assigned to manage the client’s employee claims and leaves of absence.  This position is the 1st level contact for status of the client’s employee claims and leaves of absence, as well as any issues that need to be escalated to higher levels of Matrix management for resolution. In addition, the position will provide assistance and consultation to the Manager, Client Leave Programs, including quality management and the evaluation of Matrix leave programs. The position will require the incumbent to ensure that Matrix personnel administering leaves of absence and claims for the client’s personnel are complying with Matrix best practices and standard operating procedures.

Duties and Responsibilities:

• Oversee escalated disability and leaves to confirm compliance with client policies and applicable federal/state laws.
• Coordinate escalated return to work efforts.
• Facilitate leave-related communications with the client
  • Leave Team: Managing escalated matters including return to work for employees returning from leave and requests for accommodation(s) under the Americans with Disabilities Act and related state disability laws. Benefit delivery, status changes, status updates, payroll matters and problem resolution.
  • Employees: serve as the point person for Matrix for any problems or inquiries relating to disability and leaves of absence administered by Matrix.
  • HR representatives from all sites: provide support to the Matrix claims team for general questions.
  • Supervisor/Manager: provide support on return to work status questions regarding job protection, and questions relating to absence and disability.
• Evidence of Insurability coordination for Long Term Disability.
• 1st level of communication for escalations. Identify appropriate personnel at Matrix to involve in resolutions.
• Independently investigate, evaluate and adjudicate claims with an often high degree of complexity.
• Respond to customer service issues in a timely fashion. Proactively communicate decisions within Matrix Best Practice guidelines, and assist the Matrix Claims Team to consistently meet Performance Guarantee requirements.
• Facilitate issue resolution and draw on expertise of internal Matrix personnel and client partners as needed.
• Interpret and administer policy/plan provisions.
• Fully investigate all relevant issues, including those involving healthcare providers, claim approvals, payment or denials, promptly and in full compliance with departmental procedures and unfair claims practice and regulations.
• Document claim file actions and conversations thoroughly and accurately.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.

REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE

*or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience*

• BS Degree in Business or Human Resources.

• Minimum 5 years’ experience in administration and handling of leave of absence, disability benefits, and/or worker’s compensation claims; 7 to 10 years preferred.
• Must be able to work independently but also be an effective team player with on internal and external personnel and stakeholders.
• Must have excellent verbal and written communication skills
• Demonstrates prioritization and organizational skills
• Must be self-directed and able to handle large, complex caseloads with minimal supervision
• Must demonstrate flexibility and have experience working with different types of organizations including vendors, consultants, providers, clients.
• In-depth knowledge of federal and state laws pertaining to leaves of absence and disability claims administration and adjudication.
• Knowledge of and familiarity with medical terminology required
• Ability to gather, analyze and organize data to make well-reasoned, diligent decisions.
• Ability to identify critical issues and exercise independent judgment.
• Ability to handle confidential information with the utmost judgment and discretion.

Ability to Travel: Up to 10%

PHYSICAL REQUIREMENTS

When used in the description below, the following terms are defined as:

“Occasional”: do