Responsibilities

• Evaluate and make appropriate determinations of disability claims in accordance with applicable state laws (NY and NJ) and Fund procedures
• Request required disability claim information from 1199SEIU members, physicians and employers to process new and ongoing disability claims
• Analyze and evaluate medical and vocational information to determine a member’s inability to work and to assist in return-to-work efforts while member is disabled
• Calculate accurate weekly or bi-weekly benefits based on the provisions of the Summary Plan Description (SPD) and earnings information received from employers; recalculate benefits as needed in situations where employer information was not received on time; assist with disability check releases
• Communicate with members, physicians, employers and other professionals via telephone and in writing regarding disability claim payments; provide excellent customer service to members to ensure disability claims are paid in a timely and accurate manner
• Produce manual hand checks for adjustments of rates, including sick days, first day paid and last day paid
• Complete in-depth interview with members to determine eligibility for worker’s compensation
• Refer disability claims to the appropriate support services which include medical consultants for review, Member Assistance Program (MAP) and refer members for independent medical examinations
• Process all claims assigned within the appropriate error ratios.
• Perform additional duties and projects as assigned by management
• Must meet performance standards including attendance and punctuality

Qualifications

• High School Diploma or GED required, some College or Degree preferred
• Minimum two (2) years experience examining and resolving health claims in a health insurance or benefits environment; or (2) years experience reviewing or analyzing Disability Claims required
• Knowledge of disability claims systems, Current Procedural Terminology (CPT) codes, hospital claims history and International Classification of Diseases (ICD-9) codes required
• Demonstrated knowledge of New York State, New Jersey State disability laws and appropriate benefits from other sources (i.e. worker’s compensation) for offsetting benefits preferred
• Ability to evaluate and make determinations on new disability claims and manage continuous claims
• Basic knowledge of Microsoft Excel and Word preferred
• Excellent oral and written communication skills; ability to initiate and create written correspondence
• Ability to maintain a professional manner and attire at all times; ability to maintain a pleasant attitude to ensure excellent service to members
• Able to multi-task, establish priorities, meet deadlines, and follow through on assignments
• Able to handle heavy telephone call volume