Short Term Disability​/Absence Claims Case Manager

Please note:

This is a non-exempt, remote-based position with a projected starting pay rate of $21.64 per hour, with an annual bonus target of 3%.

The STD/Absence Claims Case Manager I (CM) is responsible for administering and medically managing Short Term and Absence claims with specific diagnoses or leave types that tend to resolve quickly. The CM will work with employers, employees, and health care providers to administer Short Term disability in conjunction with other paid or unpaid leaves covered by Guardian. These leaves can be Family and Medical Leave Act (FMLA), State Paid Medical Leave, and or State Paid Disability.

The CM will manage the claim according to the plan provisions, state and federal guidelines, and established protocols. The CM must demonstrate the knowledge to work independently, interpret contract provisions, and utilize critical thinking skills for medical management to administer benefits through the appropriate claim duration or return to work. The CM is responsible for meeting key service deliverables such as turnaround times, quality assurance, and overall customer experience.

This position utilizes problem solving and analytical, written, and verbal communication skills to ensure timely and appropriate disability claim decisions while providing superior customer service to all internal and external customers. This position will review claims for Short Term Disability and requires consistent and effective claim management skills to succeed in a collaborative, team-oriented culture with a goal to drive positive claim outcomes.

• Effectively understand contract language and plan design for group disability

• Communicate claim status and decisions via telephone and in writing

• Initiate communications to claimant, physician, and plan holder to assess and facilitate job accommodation opportunities

• Proactive outreaches to claimants, plan holders, and physicians via telephone for information needed for initial and ongoing claim management (e.g. current earnings, other income benefits, medical information, etc.); notifies claimants when claims are pended for missing information

• Proactively develop and execute an appropriate plan of action for pending and ongoing disability claims assigned by utilizing, managing and directing appropriate resources. Conduct timely and accurate benefit determination in accordance with policy provisions and regulatory and internal standards while providing sound customer service to all internal and external customers

• Investigate and analyze claim information in conjunction with contract provisions to determine coverage and benefit eligibility

• Recognize and adapt to fast-paced environment

• Determine if claimants meet the definition of disability as defined in the contact by reviewing occupational level and analyzing medical information

• Establish, document and execute claim action plan and recommended path including return to active work at claimant’s own job

• Determine Insured Earnings by reviewing payroll information from the plan holder; then, calculate payable benefits according to plan provisions

• Follow all claim management procedures and facilitate potential return to work and job accommodation opportunities when applicable

• Utilize claim management resources such as MDA (Medical Disability Guidelines) and other disability tools to assist with appropriate durational disability

• Assess claim when other sources of income are received (e.g., social security, state disability, etc.,) to ensure accurate offsets are applied and recalculate benefits, as needed to determine under/over payments. Proactively work with claimants to recover over payments in full or negotiate monthly installments according to established protocols

• Assess claim for restrictions and limitations to establish appropriate partnership with PRT

• This position reports to a Team Leader, STD/Absence.

• Outstanding customer service

• Excellent analytics

• Strong math aptitude

• Ability to manage multiple priorities and meet departmental turnaround times

• Demonstrate independent problem solving and decision-making ability

• Ability to clearly communicate claim decisions and contract language verbally and in written correspondence

• Ability to multi-task, balance goals and prioritize

• Ability to work independently and within a highly collaborative team environment

• Read and interpret medical information

• Strong skillset in Microsoft Windows applications (e.g., Microsoft Word, Excel, Outlook)

• Effective and efficient time management

• Continuously strives to achieve superior results

• Expresses oneself in a confident and trustworthy manner

• Demonstrates a sense of urgency in a fast-paced work environment

• Demonstrates the ability to adapt to change

• High School Diploma or GED required.

• STD, Statutory, or Family Medical Leave (FML experience preferred or other equivalent work experience.

• Regulatory and Compliance experience is a plus

• Ability to provide…