LTD Claims Examiner Sr.

Key Responsibilities

**Other duties as assigned

Obtains and analyzes information to make claim decisions and payments on LTD, Voluntary disability and WOP claims.

The goal of the position/role is to consistently render appropriate claim determinations based on a review of all available information and the terms and provisions of the applicable policy. 

• Reviews and investigates disability claims by using telephone and written contact with the applicable parties, (claimant, employer/supervisor, credit union, treating physician, etc.) to gather pertinent data to analyze the claim.
• Adjudicates claims accurately and fairly in accordance with the contract, appropriate claim policies and procedures, and state and federal regulations, meeting productivity and quality standards based on product line.
• Utilizes appropriate medical and risk resources, adhering to referral polices, and transferring claims to the appropriate risk level in a timely manner.
• Conducts in-depth pre-existing condition or contestable investigations if applicable.
• Calculates benefit payments, which may include partial disability benefits, integration with other income sources, survivor benefits, residual disability benefits, etc.
• Develops and maintains on-line claim data (and paper file if applicable).
• Provide customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.

Analysis and Adjudication

• Fully investigates and adjudicates a large volume complex claims, does not review simple claims.
• Identifies and investigates change in Total Disability definition (any occ).
• Independently reviews and manage claims with high degree of complexity within the $3,000 per month approval authority limit.
• Independently makes the determination if a policyholder with life policy up to $225,000 is eligible for a waiver of premium. 
• May handle the claim administration for sensitive or complicated policyholders.
• Majority of work is not subject to supervisor review and approval.

Case Management

• Consistently manage assigned case load of 60-80 complex cases independently.
• Collaborates with team members and management in recommending and implementing improvement opportunities.

Miscellaneous

• Seen as subject matter expert within team and provides mentor or training support for newer Examiners to assist in their development or on claims related projects.
• Assists management in pre-sale presentations, problem/complaint investigation and resolution.
• Assists management in responding to Insurance Department inquiries and executive complaints.
• Identify trends or training needs of the team.

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*

Required Knowledge, Skills, Abilities and/or Related Experience

• High School Diploma or GED.  Associates degree in Business, Finance, Social Work, or Human Resources preferred.  Level I LOMA designation preferred.
• 5 years experience processing long term disability claims.
• Advanced understanding of claim management techniques and critical thinking in activities requiring analysis and/or investigation.
• Experience working in confidential/protected identification environments.
• Thorough knowledge of medical terminology.
• Excellent math and calculation skills.
• Proven ability to work well in a high-visibility, public-oriented environment.

Ability to Travel: None

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.

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 asset—you.

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:

• Sustainable Performance
• Continuous Improvement
• Customer Experience
• Collaboration
• Empowerment
• Sense of Community

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.