Job Responsibilities and Requirements

Responsible for processing appeals of adverse benefit determinations in all lines of business, which includes Long Term Disability (LTD), Short Term Disability (STD), Life/Waiver of Premium/Group Life products/Accelerated Death/Accidental Death/Critical Illness (and all related coverages) or other claims. 

Duties and Responsibilities:

• Reviews, evaluates, and investigates (if necessary) in a timely manner consistent with applicable regulations and company guidelines adverse benefit determinations which have been properly appealed and determine whether the adverse benefit determination was appropriate.
• Ensures the accuracy and timeliness of systems coding for the status of appealed adverse benefit determinations used in management reporting.
• Supports the achievement of established departmental goals and objectives related to claim performance including service, quality and production
• Serves as a resource for all Claims personnel regarding the proper adjudication of claims and establishment of best claims practices.
• Communicates the decision on appeal thoroughly and accurately in writing to the claimant or his/her authorized representative.
• Provides appropriate feedback to Claims management and other team members for training purposes.
• Develops and maintains strong working relationships with business partners including, but not limited to, underwriting, sales, actuarial and customer service.
• Determines whether adverse benefit determinations have been properly appealed.  All appeals should, where possible, be processed in conformity with (where applicable) the Employee Retirement Income Security Act of 1974 (ERISA) as amended and the accompanying regulations, state law and/or regulatory requirements, and in conformity with company guidelines.   
• Any other job-related duty as deemed appropriate by management

CAREER LEVEL

Professional

P2

• Requires knowledge and experience in own discipline; still acquiring higher level knowledge and skills
• Building knowledge of the organization, processes and customers
• Solves a range of straightforward problems
• Analyzes possible solutions using standard procedures
• Receives a moderate level of guidance and direction
• Supports projects or programs lead by others

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*

Education, Qualifications and Experience:

• High School Diploma or equivalent required. 
• Relevant Associates or Bachelors Degree highly preferred. 
• JD and/or the completion of HIAA, LOMA or ICA courses desirable.
• Minimum of 5 years relevant experience
• Demonstrated ability to evaluate complex Claims situations independently
• Demonstrated ability to provide feedback on Claims handling
• Demonstrated ability to communicate effectively in person, on the telephone, and effectively in writing

PHYSICAL REQUIREMENTS

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

“Occasional”: done only from time to time, but necessary when it is performed

“Frequent”: regularly performed; generally an act that is required on a daily basis

“Continuous”: typically performed for the majority of an employee’s shift

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.  Reliance Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

• Collaboration
• Compassion
• Empowerment
• Integrity
• Fun

The above description reflects the general details considered necessary to describe the principle responsibilities and functions of the job identified and shall not be construed as a detailed description of all the work requirements that may be inherent to this job.