Case Manager I, LTD
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Scarborough, ME 04074
You are as unique as your background, experience and point of view. Here, you’ll be encouraged, empowered and challenged to be your best self. You’ll work with dynamic colleagues – experts in their fields – who are eager to share their knowledge with you. Your leaders will inspire and help you reach your potential and soar to new heights. Every day, you’ll have new and exciting opportunities to make life brighter for our Clients – who are at the heart of everything we do. Discover how you can make a difference in the lives of individuals, families and communities around the world.
This position is responsible for the managing the customer service, the benefit payment process and the financial risk associated with an assigned block of long term disability claims. This requires applying the appropriate contractual provisions, legal guidelines; professional case management resources; and claims practices, procedures and protocols to the medical and occupational facts of each claim to decide on its acceptance or denial and the duration of the benefit payment.
This is accomplished by the incumbent’s determining what medical and occupational information is required to fully understand the facts of the claim, collecting it from multiple sources, e.g. claimants, employers, physicians using both written and verbal requests. The incumbent accesses the information, often in consultation with medical and vocational rehabilitation experts, to make the decision. The decision’s rationale must be communicated clearly, confidently and with sensitivity for the claimant’s circumstances.
The incumbent is accountable for developing, coordinating and implementing a plan of action for each claim accepted to ensure it is managed effectively for the duration of the disability. This management accountability for a fully trained Case Manager (typical learning curve of 12 to 18 months) extends to a caseload range of 60-85 LTD claims. A Case Manager who is new in the position is responsible for a much smaller caseload with oversight by the team’s Manager and feedback from a more experienced claims mentor.
Reviews claim payments within established authority limits and manages a group of claims on an ongoing basis to ensure appropriateness of payment of benefits. Manages claims activities and appropriate use of resources to ensure that payouts are adjudicated in a timely, accurate and efficient manner:
1. Conducts initial claim eligibility review;
2. Confirms that medical evidence supports claimant’s restrictions & limitations;
3. Obtains all pertinent and necessary information to evaluate claim credibility;
4. Prepares written rationale of claim decision based on a review of the contractual provisions and the analysis of the medical and occupational records;
5. Processes claims for payment by setting up on claim paying system to ensure accurate and timely receipt of benefit payments;
6. Develops and documents claim strategy for ongoing claim management of each file and periodically assesses the effectiveness of the action plan;
7. Prioritizes caseload and work; maintains appropriate documentation;
8. Assesses occupational job duties and rehabilitation opportunities by working with vocational staff;
9. Appropriately uses investigative tools; may testify in court cases, respond to State Insurance Department complaints/requests and provide depositions related to claim disputes based upon technical expertise.
1. Excellent written and verbal communication skills.
2. Broad grasp of claims practices; related work experience in claims or in a medical field would be helpful, particularly in the areas of worker’s compensation, long term care or medical claims.
3. Strong customer service orientation.
4. Must be able to work in a team environment.
5. Ability to speak directly with claimants in telephone interviews or in person with other Senior Analysts.
6. Solid analytical skills as well as the ability to negotiate with people.
Bachelor’s Degree preferred
Experience in individual or group disability from business or legal perspective
In-depth knowledge of LTD claim practices and claim management procedures for all claim levels.
Demonstrated expert analytical skills with the ability to think creatively and address the strengths and weaknesses of a claim and the fine distinctions in contract language.
Understanding of Social Security law, Workers’ Compensation statutes, statutory disability laws and pensions.
It is the policy of SLF U.S. that we will recruit, hire, train, and promote persons in all job titles, and ensure that all other personnel actions are administered, without regard to age, race, color, religion, national origin, ancestry, gender, sex (including but not limited to pregnancy, childbirth, or breastfeeding), sexual orientation, gender identity or expression, military or veteran status, physical or mental disability, medical condition, genetic information, marital status, or other legally protected status, and we will ensure that all employment decisions are based only on valid job requirements.
For applicants residing in California, please read our employee .
Claims – Life & Disability
Posting End Date:
Sun Life Financial is an equal employment and affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, religion, age, national origin, disability, veteran status, sexual orientation, gender identity or expression, marital status, ancestry or citizenship status, genetic information, pregnancy status or any other characteristic protected by law. Sun Life Financial is committed to building a diverse and inclusive company culture.
Sun Life Financial is a leading provider of group insurance benefits in the U.S., helping people protect what they love about their lives. More than just a name, Sun Life symbolizes our brand promise of making life brighter – for our customers, partners, and communities. Join our talented, diverse workforce and launch a rewarding career. Visit us at www.sunlife.com/us to learn more.