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Case Specialist III, STD

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Job Details
Job Order Number
499662
Company Name
Sun Life Financial (U.S.) Services Company, Inc.
Physical Address
300 Southborough Drive, Suite 200
South Portland, ME 04106
Job Description

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.

Job Description:

Job Description

The Case Specialist III, STD acts under the general supervision of a senior manager and consultant managing claims by conducting thorough reviews and investigation, determining what additional resources are appropriate to be utilized, and determining initial and ongoing liability.

The essential functions and responsibilities of this job position include, but are not limited to the following:

  • Reviews and investigates disability claims by using telephone and written contact with the applicable parties, (claimant, employer/supervisor, credit union, treating physician, etc.) to gather pertinent data to analyze the claim
  • Adjudicates claims accurately and fairly in accordance with the contract, appropriate claim policies and procedures, and state and federal regulations, meeting productivity and quality standards based on product line
  • Utilizes appropriate medical and risk resources, adhering to referral polices, and transferring claims to the appropriate risk level in a timely manner
  • Conducts in-depth pre-existing condition or contestable investigations if applicable
  • Calculates benefit payments, which may include partial disability benefits, integration with other income sources, survivor benefits, residual disability benefits, cost of living adjustments, etc.
  • Develops and maintains on-line claim data (and paper file if applicable)
  • Documents and communicates claim decisions
  • Coordinates return to work, working with vocational rehabilitation as necessary
  • As warranted, guides the claims management activities of the insurance company clients’ claims analysts on co-managed claims
  • Obtains/maintains TPA licensing and required credit hours
  • Participates in in-service and training opportunities as required
  • Acts as a mentor to new employees, conducting one-on-one training and serving as a resource
  • Assists with segment reviews
  • Assists with heavy claim loads

ADDITIONAL RESPONSIBILITIES:

  • Conducts internal and external claims audits
  • Conducts internal and external training seminars
  • Participates in the development of internal policies and procedures
  • Participates in industry or client meetings
  • Other duties and responsibilities as requested/needed

Position Requirements and Qualifications:

QUALIFICATIONS:

  • Minimum 2 years previous related work experience and short-term disability product line experience required
  • Attains and maintains appropriate TPA licenses in accordance with the Claims Licensing Policy
  • Ability to train and mentor new employees
  • Ability to work in self-directed manner with minimal assistance from the consultant or manager
  • Exposure to various issues within specific disability product line with demonstrated experience in generating and selecting solutions to resolve those issues
  • Solid analytical, critical thinking, problem solving and decision-making skills
  • Ability to interpret and communicate disability contract language
  • Excellent verbal communication skills, with the ability to be both pleasant and professional
  • Strong written communication skills
  • Solid mathematical skills
  • Ability to work well independently and in a team environment
  • Strong interpersonal and customer service skills
  • Ability to initiate and prioritize regular work duties and projects
  • Detail oriented, organized, the ability to multi-task, and strong time management skills
  • Strong computer skills, proficient in a PC environment and MS Word, Excel, and email systems
  • Ability to work professionally and effectively with co-workers, clients, claimants, vendors and others with whom DRMS does business

The Case Specialist III, STD acts under the general supervision of a senior manager and consultant managing claims by conducting thorough reviews and investigation, determining what additional resources are appropriate to be utilized, and determining initial and ongoing liability.

The essential functions and responsibilities of this job position include, but are not limited to the following:

  • Reviews and investigates disability claims by using telephone and written contact with the applicable parties, (claimant, employer/supervisor, credit union, treating physician, etc.) to gather pertinent data to analyze the claim
  • Adjudicates claims accurately and fairly in accordance with the contract, appropriate claim policies and procedures, and state and federal regulations, meeting productivity and quality standards based on product line
  • Utilizes appropriate medical and risk resources, adhering to referral polices, and transferring claims to the appropriate risk level in a timely manner
  • Conducts in-depth pre-existing condition or contestable investigations if applicable
  • Calculates benefit payments, which may include partial disability benefits, integration with other income sources, survivor benefits, residual disability benefits, cost of living adjustments, etc.
  • Develops and maintains on-line claim data (and paper file if applicable)
  • Documents and communicates claim decisions
  • Coordinates return to work, working with vocational rehabilitation as necessary
  • As warranted, guides the claims management activities of the insurance company clients’ claims analysts on co-managed claims
  • Obtains/maintains TPA licensing and required credit hours
  • Participates in in-service and training opportunities as required
  • Acts as a mentor to new employees, conducting one-on-one training and serving as a resource
  • Assists with segment reviews
  • Assists with heavy claim loads

ADDITIONAL RESPONSIBILITIES:

  • Conducts internal and external claims audits
  • Conducts internal and external training seminars
  • Participates in the development of internal policies and procedures
  • Participates in industry or client meetings
  • Other duties and responsibilities as requested/needed

Position Requirements and Qualifications:

QUALIFICATIONS:

  • Minimum 2 years previous related work experience and short-term disability product line experience required
  • Attains and maintains appropriate TPA licenses in accordance with the Claims Licensing Policy
  • Ability to train and mentor new employees
  • Ability to work in self-directed manner with minimal assistance from the consultant or manager
  • Exposure to various issues within specific… For full info follow application link.

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.


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