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

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