Claims Specialist, Worksite
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South Portland, ME 04106
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.
The Worksite Claim Specialist manages initial liability claims submitted for Worksite Accident benefits and wellness and screening benefits. They work independently and autonomously managing each claim by conducting a thorough review and investigation, determining what additional resources are appropriate to collaborate with and deciding the initial and future liability of each claim.
The essential functions and responsibilities of this job position include, but are not limited to the following:
- Reviews and investigates worksite accident, wellness, and screening claims by using telephone and written contact with the applicable parties, e.g. claimant, employer, treating physicians and client carrier partner, to gather pertinent data to analyze each claim.
- Investigates the claim level eligibility by accessing the client carriers’ systems (up to six different systems)
- Resolves eligibility issues by collaborating with employers and partners at the client company
- Adjudicates claims and benefits accurately and fairly and in accordance with the contract, appropriate policies and procedures, state and federal regulations, while meeting strict productivity and quality standards.
- Utilizes clinical staff, adhering to referral policies and transferring claims to the appropriate risk level in a timely manner
- Thoroughly reviews all medical records submitted to accurately calculate and communicate all benefits payable in a timely manner
- Ability to interpret, understand and communicate the Accident policy that governs each claim
- Develops and maintains online claims data
Position Requirements and Qualifications:
- Minimum 1 year previous work experience in financial, medical or customer service field
- High School Diploma required, college degree preferred
- Attains and maintains appropriate TPA licenses in accordance with the Claims Licensing Policy
- 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
Disability RMS 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.
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.