STD Claims Examiner

RO Portland ME
South Portland, ME 04106, USA

At One America, we deliver on promises when customers need us most. We believe the best way to serve our customers is to know that every individual, employee, family and business we work with has unique personal and financial goals. We keep our promises, so we can help them achieve their goals and realize their definition of financial success.

The STD Claims Examiner is responsible for contributing to the overall success of One America objectives by providing timely and accurate support to our client companies and the Claims department. This individual will be responsible for managing appropriate adjudication of short-term disability claims in accordance with policy provisions. The STD Claims Examiner will initiate and facilitate case management as well as other ancillary services to assure optimum outcomes.

• Promotes a positive customer service image through prompt, accurate and courteous responses to customer information needs.
• Consistently adheres to the documented workflow guidelines and established procedures.
• Maintains required levels of confidentiality.
• Demonstrates competency in all modules of training program. Remains abreast of industry standards via internal/external continuing education.
• Promptly and thoroughly investigates and evaluates claims within departmental and regulatory guidelines.
• Interprets and administers contract provisions including, but not limited to, eligibility, covered weekly earnings, definition of Total Disability, verification of applicable offsets and pre-existing investigations.
• Calculates benefit and identifies other income replacement benefits. Processes financial activities, including, but not limited to, payment adjustments, stop payments, voids and check reissues, other income adjustments, reimbursement checks, and final benefits. Processes over payments in accordance with established procedures.
• Assists in the subrogation process to recover money from third parties.
• Works in coordination with an LTD Examiner to ensure an appropriate transition from the STD claim to LTD.
• Documents claim file actions and telephone conversations appropriately.
• Refers claim activity outside authority level to Supervisor/Manager for review.
• Proactively communicates with claimants, policyholders and physicians to resolve investigations issues.
• Establishes, communicates and manages claimant and policyholder expectations.
• Utilizes most efficient means to obtain claim information.
• Fully investigates all relevant claim issues, provides payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations.
• Responds to customer service issues within required time frames.
• Involves technical resources (Social Security Specialist, medical resources and vocational resources) at appropriate claim junctures.
• Supports relationships with technical resources to achieve appropriate outcomes
• Meets or exceeds departmental service, quality and production objectives.

Collaborates with team members and management in identifying and implementing improvement opportunities. Informs Supervisor of any trends noted within specific client companies.

All other duties as assigned.

We are currently seeking Level I, Level II, or Sr Level experience.

• BA/BS or equivalent combination of education and experience.
• 5+ years of experience in managing Short Term Disability claims with first pay authority.
• Ability to fluently speak and write Spanish a plus.
• Excellent math and calculation skills.
• Good decision making skills – able to analyze complex claim information.
• Working knowledge of Microsoft Excel and Word.

Salary Band: 04B

This selected candidate will be expected to work hybrid in Indianapolis,…