Short Term Disability/Absence Claims Case Manager at Guardian in Bethlehem, PA

Position Summary
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.
Candidate Responsibilities

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 planholder to assess and facilitate job accommodation opportunities
Proactive outreaches to claimants, planholders, 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 planholder; 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/overpayments. Proactively work with claimants to recover overpayments in full or negotiate monthly installments according to established protocols
Assess claim for restrictions and limitations to establish appropriate partnership with PRT

Reporting Relationships
This position reports to a Team Leader, STD/Absence.
Skills

Outstanding customer service skills
Excellent analytical skills
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 in a professional manner 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

Success Factors and Leadership Behaviors

Takes ownership to deliver quality results in a timely manner
Expresses oneself in a confident, authentic and respectful manner
Demonstrates a sense of urgency in a fast-paced work environment
Demonstrates the ability to adapt to change

Position Qualifications

High School Diploma or GED Required
Short Term Disability, Statutory, or Family Medical Leave (FML) experience preferred or other equivalent work experience.
Regulatory and Compliance experience is a plus
Ability to provide exceptional customer service by communicating clearly and professionally
Ability to prioritize and multi-task while navigating through multiple business applications in a fast-paced team environment

Successful completion of a job-related assessment is required

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