Claims Examiner NY DBL/PFL

Key Responsibilities

Job Responsibilities and Requirements • other duties as assigned* The Claims Examiner I obtains and analyzes data for thorough, fair, objective, and timely adjudication of NY State Short Term Disability and Paid Family Leave claims. The goal of the position/role is to consistently pay the accurate amount for each claim in accordance with the current laws/regulations. Research • Develop an understanding and working knowledge of disability and paid family leave • Develop an understanding of the applicable claim definitions and relevant provisions, clauses, exclusions, riders and waivers for the necessary requirements. • Develop an operating knowledge of the applicable claims system(s). • Develop basic claims skills and an understanding of claim practices and procedures. • Utilizes most efficient means to obtain claim information. Analysis and Adjudication • Fully investigates all relevant claim issues with oversight by Manager when needed. • Provides payment or denials promptly and in full compliance with department procedures and regulations. • Researches specifics regarding eligibility and pre-existing formulas in reference to specific claim. • Pro-actively communicates with claimants, policyholders, and physicians when applicable Case Management • Utilizes appropriate intervention for the characteristics of each claim. • Manages assigned case load and processes within the specified time requirements. • Good written documentation that provides clear, concise and accurate information to claimants as well as within the claims administrative system. Customer Service • Provide customer service that is respectful, prompt, concise, and accurate in an environment with competing demands. • Establishes, communicates, and manages claimant and policyholder expectations. • Documents claim file actions and telephone conversations appropriately. • Ability to handle confidential information with the Apply Job!