Claims Examiner II - SSL

Claims Examiner I

The Claims Examiner I obtains and analyzes data for thorough, fair, objective, and timely processing of New York State statutory Short-Term Disability and Paid Family leave claims. The goal of the position/role is to consistently pay the accurate amount for each claim in accordance with the current laws/regulations.

Research

• Develop an understanding and working knowledge of disability and paid family leave
• Develop an understanding of the applicable claim definitions and relevant provisions, clauses, exclusions, riders and waivers for the necessary requirements.
• Develop an operating knowledge of the applicable claims system(s).
• Develop basic claims skills and an understanding of claim practices and procedures.
• Utilizes most efficient means to obtain claim information.

Analysis and Adjudication

• Fully investigates all relevant claim issues with oversight by Manager when needed.
• Provides payment or denials promptly and in full compliance with department procedures and regulations.
• Researches specifics regarding eligibility and pre-existing formulas in reference to specific claim.
• Pro-actively communicates with claimants, policyholders, and physicians when applicable

Case Management

• Utilizes appropriate intervention for the characteristics of each claim.
• Manages assigned case load and processes within the specified time requirements.
• Good written documentation that provides clear, concise and accurate information to claimants as well as within the claims administrative system.

Customer Service

• Provide customer service that is respectful, prompt, concise, and accurate in an environment with competing demands.
• Establishes, communicates, and manages claimant and policyholder expectations.
• Documents claim file actions and telephone conversations appropriately.
• Ability to handle confidential information with the utmost judgment and discretion

Required Knowledge, Skills, Abilities and/or Related Experience

• High school diploma (or equivalent)
• Must have 1-3 years of New York State statutory Disability and Paid Family leave claims processing experience to be considered for this role.
• Experience with Microsoft Office
• Work experience in decision-making and information analysis.
• Demonstrated prioritization and organization skills.
• Ability to communicate clearly and succinctly verbally and in writing
• Must be able to work in a team oriented environment.
• Meet and exceed production, attendance, quality and service
• Ability to organize work, manage time and follow through
• Availability to work overtime when required

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