LTD Claims Examiner II

Claims ProcessorObtains and analyzes information to make claim decisions and payments on LTD, Voluntary disability and Waiver of Premium claims. Reviews and investigates disability claims by using telephone and written contact with the applicable parties 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). Provides customer service that is respectful, prompt, concise, and accurate in an environment with competing demands. Fully investigates and adjudicates a large volume simple to complex claims. Identifies and investigates change in Total Disability definition (any occ). Independently reviews and manages claims with high degree of complexity within the $1,500 per month approval authority limit. Independently makes the determination if a policyholder with life policy up to $125,000 is eligible for a waiver of premium. Consistently manage assigned case load of 60-80 simple to complex cases independently. Collaborates with team members and management in identifying and implementing improvement opportunities. 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. 2 years experience processing long term disability claims. Demonstrated understanding of claim management techniques and critical thinking in activities requiring analysis and/or investigation. Experience working in confidential/protected identification environments. Knowledge of medical terminology. Good math and calculation skills. Proven ability to work well in a high-visibility, public-oriented environment. Ability to Travel: None 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.