Group Life Claims Case Manager II

The Group Life Claims Case Manager II is responsible for paying Group Life and AD&D Insurance claims to our planholder's beneficiaries. As a part of this position, you will spend 6-8 weeks in eligibility training followed by at least 3 months of reviewing live eligibility claims while being mentored. You will then begin to build an active claim caseload while being mentored on benefit determinations. Once released from mentoring, you will be subject to 5 months of audits for learning and extra training purposes.

This position uses problem solving, analytical, written, and verbal communication skills to deliver timely and appropriate disability claim decisions while providing outstanding customer service to all internal and external customers. After the training periods have ceased, you will make all decisions on assigned claims through proactive case management according to the plan provisions, state and federal guidelines, and established protocols. This position consults with the mentors and other team members.

This role administers claims within a variety of group sizes ranging from small (2+ lives) to large market (1000+ lives). This position is responsible for ensuring all plan provisions are satisfied to make an eligibility determination. The Group Life Case Manager II consults with Group Life Case Manager III /Mentors, management, legal, and investigative resources.

You have

• High School Diploma or GED required.
• 5+ plus years of Group Life Claims Case Manager experience.
• Outstanding customer service skills.
• Excellent analytical skills.
• Strong math proficiency skills and PC skills (e.g., Microsoft Word & Excel).
• Ability to multi-task and meet 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 work independently and within a highly collaborative team environment.
• Claim experience or product knowledge strongly preferred.
• Regulatory and Compliance experience a plus.
• Understanding of medical terminology helpful.

You will

• Investigate and analyze claim information to determine coverage and benefit eligibility.
• Perform accidental death investigation and draft adverse determination letter if applicable.
• Perform contestability investigation, evaluate for possible rescission, make rescission determination, and draft rescission letter if applicable.
• Perform dependent confinement investigation and draft adverse decision letter if applicable.
• Determine Insured Earnings by reviewing payroll records, tax returns (including W2s), and partnership records and calculate payable benefits according to plan provisions within payment authority assigned by management.
• Track and record statistical data such as benefit volumes and ICD9 codes for reserves, reports, and future profitability.
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