Claims Examiner Team Lead - AMS

KEY RESPONSIBILITIES

*other duties as assigned*

Responsible for supporting both the supervisor and examiners in the day-to-day operation of the claim team. The Claims Team Lead will also be responsible for developing and sustaining excellent internal partnerships with other areas in the company.

In addition, the Claims Team Lead will act as an examiner when needed to balance workloads.  In this role, they would be accountable for the decision making process for determining eligibility under federal, state laws and client policy. Secure and analyze information to make and approve decisions on all short-term disability, insured or self-insured, and/or statutory claims and their concurrent leave claims. Develop and apply appropriate claim and workflow management strategies, coordinating both disability and leave decisions while meeting timeliness regulations.

Duties and Responsibilities:

• Supports the achievement of established departmental goals and objectives related to all claim operations in compliance with the Claim Organization’s standards
• Supports both the supervisor for team leadership, as well as the individual examiners to provide day-to-day guidance and workload balancing.
• Partners with Claim Operations leaders to review specific claims that fall within defined parameters to better understand claim trends, training opportunities, coaching opportunities, and/or performance management opportunities.
• Supports all training and coaching activities through communications via phone, email and video follow-up with examiners/supervisors.
• Develops and maintains strong working relationships with business partners. Reviews claims to ensure that decisions related to eligibility, disability, offsets, benefit calculations and ongoing claim management are accurate and appropriate. Ensures achievement of specific customer service, quality and production objectives.
• Ensures claim process consistency through continuous communication and feedback with the examiners/supervisor.
• Responsible for assisting in reviewing and completing monthly reports 
• Ability to interact and respond to both internal and external customers regarding claim results.
• Ability to prioritize and manage changing workloads, meeting deadlines independently and through management of others.
• Ability and knowledge to assist with claim denial reviews. 
• Ability to assist in claim auditing.  
• Completion of Mentor Training and successful completion of one year of mentoring.
• Collaborates with team members and management in identify and implementing improvement opportunities.
• Ability to participate in finalist presentations and ongoing client meetings.
• Ability to review audit findings and prepare rebuttals.
• Ability to back up supervisor in periods of extended absences or vacations
• Ability to back up examiners in periods of high volume or extended absences/vacations with the following duties and responsibilities:
  • Responds to customer service issues within required timeframes.  Pro-actively communicates decisions within Best Practice guidelines, consistently meeting Performance Guarantee requirements.
  • Determining eligibility under federal and state requirements for leaves submitted and determines eligibility under client’s plan/policy.   
  • Medical certification review and management supplied by the healthcare provider.
  • Makes determinations to approve, deny or delay and or reach out to additional resources for review. 
  • Determining the duration associated with the leave and or disability based on the information given by the healthcare provider.
  • Communicating approvals, denials, leave extensions, return to work plans and other important information regarding the leave to the employee and client. 
  • Managing leaves that are concurrent with Short Term Disability and Workers’ Compensation. 
  • Managing intermittent, continuous and client specific leaves of absences.
  • Processing all leaves within the specific timeframes outlined within Matrix Best Practices guidelines.
  • Facilitate issue resolution and draw on expertise of internal partners as needed. 
  • Ability to interpret and administer policy/plan provisions Fully Investigates all relevant issues, providers, payment or denials, promptly and in full compliance with departmental procedures and unfair claims practice and regulations. 
  • Manages self-insured business in accordance with client’s plans and custom requirements.
  • Basic knowledge of ERISA.
  • Ability to calculate earnings and benefit levels.
  • Document claim file actions and conversations thoroughly.
  • Fully Investigates all relevant issues, providers, payments.

• Demonstrates ability to independently investigate, evaluate and adjudicate claims of high degree of complexity.  Any other job-related duty as deemed appropriate by management

REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE

*or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience*

Required Knowledge, Skills, Abilities and/or Related Experience

• Associate’s Degree or equivalent required.  Bachelor’s Degree preferred.   
• Completion of HIAA, LOMA or ICA courses desirable.
• Minimum of 5 years relevant experience
• Demonstrated ability to handle multiple competing priorities.
• Demonstrated ability to provide feedback on Claims handling
• Demonstrated ability to function with limited supervision.  Demonstrated ability to work well in a high visibility environment, with excellent written and verbal communication skills.

Ability to Travel: Up to 10%

PHYSICAL REQUIREMENTS

When used in the description below, the following terms are defined as:

“Occasional”: done only from time to time, but necessary when it is performed

“Frequent”: regularly performed; generally an act that is required on a daily basis

“Continuous”: typically performed for the majority of an employee’s shift

Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand.  Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading. Employee is required to have hearing sufficient to understand verbal instruction and answer telephones.  Reliance Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

• Collaboration
• Compassion
• Empowerment
• Integrity
• Fun

The above description reflects the general details considered necessary to describe the principle responsibilities and functions of the job identified and shall not be construed as a detailed description of all the work requirements that may be inherent to this job.

Work location may be flexible if approved by the Company.

What We Offer

At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can’t do this without our most important asset—you.

That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing.  

Our Benefits:

• An annual performance bonus for all team members
• Generous 401(k) company match that is immediately vested
• A choice of three medical plans (that include prescription drug coverage) to suit your unique needs.  For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
• Multiple options for dental and vision coverage
• Company provided Life & Disability Insurance to ensure financial protection when you need it most
• Family friendly benefits including Paid Parental Leave & Adoption Assistance 
• Hybrid work arrangements for eligible roles
• Tuition Reimbursement and Continuing Professional Education
• Paid Time Off – new hires start with at least 20 days of PTO per year in addition to nine company paid holidays.  As you grow with us, your PTO may increase based on your level within the company and years of service. 
• Volunteer days, community partnerships, and Employee Assistance Program
• Ability to connect with colleagues around the country through our Employee Resource Group program

Our Values:

• Integrity
• Empowerment
• Compassion
• Collaboration
• Fun

EEO Statement

Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications.