Benefit Analyst I
Incumbent is responsible for managing a caseload of long term disability/life waiver claims including the benefit payment, risk management and customer service associated with the caseload. This requires applying the appropriate policy provisions and department procedures to the medical and occupational facts of each claim to determine if benefits are payable or not payable.
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.
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.
Sun Life Financial - 17 months ago
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