Director, Claims

Overview

A Disability Claims Director oversees the process of reviewing and managing disability claims, ensuring compliance with applicable company policy, contract language and regulations by evaluating medical records, coordinating with providers, and communicating with claimants to determine eligibility for benefits. They are responsible for managing the entire claims lifecycle, resolving disputes, detecting fraud, and improving operational efficiency through strong analytical and communication skills. 

Responsibilities

• The Director will review medical records, policy guidelines, contract language and financial information to assess claim validity and determine financial liability. 
• Review AEBA nurse recommendations including referrals for IMEs.
• They collaborate with healthcare providers, vocational experts, and other resources to gather necessary information (e.g., medical records to verify diagnoses and treatment plans) for a thorough and complete claim evaluation. 
• The Director reaches out to employers to verify if Claimant is working, appropriate return to work if Claimant is not working, and if possible light duty available.  
• Director acts as a point of contact for Claimant, providing updates on claim status, explaining the claims process, and addressing related Claimant inquiries. 
• Ensures that the claims are processed in accordance with relevant legal regulations and applicable company policies is a core responsibility. 
• Director is involved in identifying potential fraud within the claims process. 
• Work to resolve issues and disputes that may arise during the claims process including, but not limited to, working with AEBA’s Appeals Department and relevant state regulatory agencies. 
• Director implements best practices to enhance efficiency and effectiveness in claims processing. 

Qualifications

• A degree in insurance, healthcare, or a related field and/or extensive work experience handling and processing disability claims.
• The ability to analyze complex information from various sources, including contract terms, conditions, limitations and exclusions, is crucial for accurate decision-making.
• A deep understanding of insurance policies, medical terminology, and relevant regulations (i.e., disability laws) is essential.
• Both written and verbal communication, including empathetic listening and a high level of customer service, is vital for interacting with Claimants and stakeholders.
• Meticulous attention to detail ensures accuracy in claim assessment, determination and documentation.
• Compassionate customer service is important when working with Claimants navigating challenging personal circumstances.
• Familiarity with the software and systems used for disability claims processing is required.