Claims Examiner II - NY State Statutory DBL and PFL

Job Responsibilities and Requirements KEY RESPONSIBILITIES
* other duties as assigned
* The Claims Examiner II obtains and analyzes data for thorough, fair, objective, and timely adjudication of NY State Short Term Disability and Paid Family Leave claims. The goal of the position/role is to consistently evaluate each claim in accordance with the current laws/regulations.

Research Correctly applies knowledge of the NYS Disability and Paid Family Leave laws/regulations.

Accurately interprets and applies definitions of the law requirements.

Evaluate claim information in a fair and objective manner.

Use of applicable claims system(s) to generate payments, denials and letters.

Applies claims skills, practices, and procedures.

Utilizes most efficient means to obtain claim information.

Demonstrates resourcefulness and curiosity to obtain information that is not immediately apparent.

Analysis and Adjudication Fully investigates all relevant claim issues including complex claims.

Provides payment or denials promptly and in full compliance with department procedures and regulations.

Pro-actively communicates with claimants, policy-holders, and physicians when applicable to obtain necessary information.

Utilize appropriate intervention for the characteristics of each claim.

Effectively manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities.

Strong written documentation that provides clear, concise and accurate information to claimants as well as within the claims administrative system.

Case Management Utilizes appropriate intervention for the characteristics of each claim

Manages assigned case load and processes within the specified time requirements.

Collaborates with team members and management in identifying and implementing improvement opportunities. Manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities. Consistently remain within workflow guidelines on diaries and casework & adjust desk management if needed. Provides clear, concise and accurate information to claimants as well as the claims administrative system. Maintains the highest level of confidentiality when handling PII and PHI and ensures that all information is used exclusively for claim evaluation and adjudication purposes, in accordance with applicable laws, regulations, and company policies.

Customer Service Provide customer service that is respectful, prompt, concise, and accurate in a fast-paced environment with competing demands. Establishes, communicates, and manages claimant and policy-holder expectations. Documents claim file actions and telephone conversations appropriately Maintain professional client relationships Ability to handle confidential information with the utmost judgment and discretion.

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 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.

Demonstrated understanding of NYS Disability and Paid Family Leave laws/regulations

Demonstrated understanding of claim management techniques.

Work experience in decision-making and information analysis.

Experience with Microsoft Office 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.

Proven ability to meet and exceed…