Claims Examiner Sr.- Absence Management Specialist

Claims Examiner Sr. - Absence Management Specialist

The Claims Examiner Sr. - Absence Management Specialist is accountable for utilizing independent judgment and discretion in the decision making process for determining eligibility under federal, state laws and client policy. Secure and analyze information to make and approve decisions on all short term disability, insured or self-insured, and / or statutory claims and their concurrent leave claims. Develop and apply appropriate claim and workflow management strategies, coordinating both disability and leave decisions while meeting timeliness regulations.

Duties and Responsibilities :

• Responds to customer service issues within required timeframes. Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements.
• This role will manage multiple lines of business to include anything from disability, leave of absence, and Voluntary
• Determining eligibility under federal and state requirements for leaves submitted and determines eligibility under client's plan / policy.
• Medical certification review and management supplied by the healthcare provider.
• Independently, makes determinations to approve or delay to reach out to additional resources for review.
• Has independent authority to approve disability claims up to a dollar amount at least twice that of an AMS II examiner.
• Tasked with reviewing and independently approving claim denial decisions for lower-level claims examiners.
• Determining the duration associated with the leave and or disability based on the information given by the healthcare provider.
• Due to the increased experience and skill, this role is targeted to work on high profile and complex client matters.
• Communicating approvals, denials, leave extensions, return to work plans and other important information regarding the leave to the employee and client.
• Managing leaves that are concurrent with Short Term Disability and Workers' Compensation.
• Managing intermittent, continuous and client specific leaves of absences.
• Processing all leaves within the specific timeframes outlined within Matrix Best Practices guidelines.
• Facilitate issue resolution and draw on expertise of internal partners as needed.
• Ability to interpret and administer policy / plan provisions. Fully Investigates all relevant issues, providers, payment or denials, promptly and in full compliance with departmental procedures and unfair claims practice and regulations.
• Manages self-insured business in accordance with clients plans and custom requirements.
• Ability to accurately and consistently calculate earnings and benefit levels
• Document claim file actions and conversations thoroughly
• Fully Investigates all relevant issues, providers, payments
• Collaborates with team members and management in identify and implementing improvement opportunities
• Participate in finalist presentations and on-going client meetings
• Review audit findings and prepare rebuttals
• Ability to assist supervisor in periods of extended absences or vacations. Providing support and managing additional task work for team members as needed, participant in escalation research and client calls.
• Conducts audits of lower-level claim examiner's work and provides coaching, feedback, and support.
• Provides mentorship for new hire claim examiners.

All other duties as assigned.

Required Knowledge, Skills, Abilities, Competencies, and / or Related Experience :

High School Diploma and least three to five years of claims experience required. Bachelor's degree preferred.

In depth knowledge of federal and state laws pertaining to leaves of absence.

Basic knowledge of ERISA

Knowledge of medical terminology required

Professional written and verbal communication and interpersonal skills.

Strong reading, writing, and arithmetic skills required.

Ability to gather, analyze and organize data to make educated decisions.

Ability to identify critical issues and exercise independent judgment.

Demonstrates ability to independently investigate, evaluate and adjudicate claims of high degree of complexity.

Demonstrates the ability and knowledge to assist with claim denial reviews and approval of worksheets

Demonstrate the ability to assist in claim auditing

Completion of Mentor Training and successful completion of one year of mentoring

Proficient in the use of Microsoft programs; Excel and Word.

Typing proficiency at 45 wpm

Experience using web based programs

Demonstrates prioritization and organizational skills

Ability to meet deadlines while balancing competing demands

Critical thinking and analytical skills

Additional qualifications :

Excellent math, verbal and business writing skills, good reading comprehension.

Ability to organize work, manage time and follow through.

Ability to communicate effectively, both orally and in writing.

Proven experience in providing internal and external customer service.

Ability to handle confidential information with the utmost judgment and discretion.

Ability to Travel : None

Physical Requirements :

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 objects 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 expected hiring range for this position is $56,120.00 - $70,160.00 annually for work performed in the primary location (South Portland, ME). This expected hiring range covers only base pay and excludes any other compensation components such as commissions or incentive awards. The successful candidate's starting base pay will be based on several factors including work location, job-related skills, experience, qualifications, and market conditions. These ranges may be modified in the future.

Work location may be flexible if approved by the Company.

What We Offer

At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can't do this without our most important assetyou.

That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing.

Our Benefits :

An annual performance bonus for all team members

Generous 401(k) company match that is immediately vested

A choice of three medical plans (that include prescription drug coverage) to suit your unique needs. For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account

Multiple options for dental and vision coverage

Company provided Life & Disability Insurance to ensure financial protection when you need it most

Family friendly benefits including Paid Parental Leave & Adoption Assistance

Hybrid work arrangements for eligible roles

Tuition Reimbursement and Continuing Professional Education

Paid Time Off new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of service.

Volunteer days, community partnerships, and Employee Assistance Program

Ability to connect with colleagues around the country through our Employee Resource Group program

Our Values :

Integrity

Empowerment

Compassion

Collaboration

Fun

EEO Statement

Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications.