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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