Apply on Employer Site

Reliance Matrix · 1 day ago

STD Claims Examiner Team Lead

United States

Full-time

Remote

Mid, Senior Level

$64K/yr - $86K/yr

5+ years exp

Reliance Matrix is a company focused on providing excellent support in claims management. They are seeking a Claims Examiner Team Lead to oversee day-to-day operations, develop partnerships, and ensure compliance with relevant laws and policies in managing short-term disability claims.

Employee BenefitsFinancial ServicesInsuranceMental HealthRetirement

Responsibilities

Supports the achievement of established departmental goals and objectives related to all claim operations in compliance with the Claim Organization’s standards

Supports both the supervisor for team leadership, as well as the individual examiners to provide day-to-day guidance and workload balancing

Partners with Claim Operations leaders to review specific claims that fall within defined parameters to better understand claim trends, training opportunities, coaching opportunities, and/or performance management opportunities

Supports all training and coaching activities through communications via phone, email and video follow-up with examiners/supervisors

Develops and maintains strong working relationships with business partners. Reviews claims to ensure that decisions related to eligibility, disability, offsets, benefit calculations and ongoing claim management are accurate and appropriate. Ensures achievement of specific customer service, quality and production objectives

Ensures claim process consistency through continuous communication and feedback with the examiners/supervisor

Responsible for assisting in reviewing and completing monthly reports

Ability to interact and respond to both internal and external customers regarding claim results

Ability to prioritize and manage changing workloads, meeting deadlines independently and through management of others

Ability and knowledge to assist with claim denial reviews

Ability to assist in claim auditing

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

Collaborates with team members and management in identify and implementing improvement opportunities

Ability to participate in finalist presentations and ongoing client meetings

Ability to review audit findings and prepare rebuttals

Ability to back up supervisor in periods of extended absences or vacations

Ability to back up examiners in periods of high volume or extended absences/vacations with the following duties and responsibilities:

Responds to customer service issues within required timeframes. Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements

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

Makes determinations to approve, deny or delay and or reach out to additional resources for review

Determining the duration associated with the leave and or disability based on the information given by the healthcare provider

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 client’s plans and custom requirements

Basic knowledge of ERISA

Ability to calculate earnings and benefit levels

Document claim file actions and conversations thoroughly

Fully Investigates all relevant issues, providers, payments

Demonstrates ability to independently investigate, evaluate and adjudicate claims of high degree of complexity. Any other job-related duty as deemed appropriate by management

Qualification

Claims ManagementEligibility DeterminationDisability Claims ProcessingERISA KnowledgeHIAA/LOMA/ICA CoursesCommunication SkillsTeam LeadershipProblem SolvingTime Management

Required

Associate's Degree or equivalent required

Minimum of 5 years relevant experience

Demonstrated ability to handle multiple competing priorities

Demonstrated ability to provide feedback on Claims handling

Demonstrated ability to function with limited supervision

Demonstrated ability to work well in a high visibility environment, with excellent written and verbal communication skills

Ability to interact and respond to both internal and external customers regarding claim results

Ability to prioritize and manage changing workloads, meeting deadlines independently and through management of others

Ability and knowledge to assist with claim denial reviews

Ability to assist in claim auditing

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

Ability to participate in finalist presentations and ongoing client meetings

Ability to review audit findings and prepare rebuttals

Ability to back up supervisor in periods of extended absences or vacations

Ability to back up examiners in periods of high volume or extended absences/vacations

Ability to interpret and administer policy/plan provisions

Basic knowledge of ERISA

Ability to calculate earnings and benefit levels

Document claim file actions and conversations thoroughly

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

Preferred

Bachelor's Degree preferred

Completion of HIAA, LOMA or ICA courses desirable

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