Claims Examiner II - NY State Statutory DBL and PFL

Job Responsibilities and Requirements

KEY RESPONSIBILITIES

*other duties as assigned*

The Claims Examiner II 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 evaluate each claim in accordance with the current laws/regulations.

Research

• •Correctly applies knowledge of the NYS Disability and Paid Family Leave laws/regulations.
• •Accurately interprets and applies definitions of the law requirements.
• •Evaluate claim information in a fair and objective manner.
• •Use of applicable claims system(s) to generate payments, denials and letters.
• •Applies claims skills, practices, and procedures.
• •Utilizes most efficient means to obtain claim information.
• •Demonstrates resourcefulness and curiosity to obtain information that is not immediately apparent.

Analysis and Adjudication

• •Fully investigates all relevant claim issues including complex claims.
• •Provides payment or denials promptly and in full compliance with department procedures and regulations.
• •Pro-actively communicates with claimants, policy-holders, and physicians when applicable to obtain necessary information.
• •Utilize appropriate intervention for the characteristics of each claim.
• •Effectively manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities.
• •Strong written documentation that provides clear, concise and accurate information to claimants as well as within the claims administrative system.

• •Case Management Utilizes appropriate intervention for the characteristics of each claim
• •Manages assigned case load and processes within the specified time requirements.
• •Collaborates with team members and management in identifying and implementing improvement opportunities. Manages appropriate volumes, consistently meeting turnaround times, high activity levels, and quality focus on timely claim activities. Consistently remain within workflow guidelines on diaries and casework & adjust desk management if needed. Provides clear, concise and accurate information to claimants as well as the claims administrative system. Maintains the highest level of confidentiality when handling PII and PHI and ensures that all information is used exclusively for claim evaluation and adjudication purposes, in accordance with applicable laws, regulations, and company policies.

Customer Service Provide customer service that is respectful, prompt, concise, and accurate in a fast-paced environment with competing demands. Establishes, communicates, and manages claimant and policy-holder expectations. Documents claim file actions and telephone conversations appropriately Maintain professional client relationships Ability to handle confidential information with the utmost judgment and discretion.

REQUIRED KNOWLEDGE, SKILLS, ABILITIES, COMPETENCIES, AND/OR RELATED EXPERIENCE

*or equivalent experience gained from any combination of formal education, on-the-job training, and/or work and life experience*

Required Knowledge, Skills, Abilities and/or Related Experience

High school diploma (or equivalent)

Must have 1-3 years of New York State statutory Disability and Paid Family leave claims processing experience to be considered for this role.

Demonstrated understanding of NYS Disability and Paid Family Leave laws/regulations

• •Demonstrated understanding of claim management techniques.
• •Work experience in decision-making and information analysis.

• •Experience with Microsoft Office
• •Demonstrated prioritization and organization skills.
• •Ability to communicate clearly and succinctly verbally and in writing
• •Must be able to work in a team oriented environment.

• •Proven ability to meet and exceed production, attendance, quality and service
• •Ability to understand processes and identify improvements when needed
• •Ability to organize work, manage time and follow through
• •Availability to work overtime when required

Ability to Travel: None

COMPETENCIES

· Collaboration

· Drive for Excellence

· Communication

· Learning Agility

· Leading Self

· Leading Others (keep for people leaders only, remove for individual contributors)

PHYSICAL REQUIREMENTS

If there are additional physical requirements not captured below, please provide a general overview of these requirements and HR will follow up if more detailed analysis is required.

When used in the description below, the following terms are defined as:

“Occasional”: done only from time to time, but necessary when it is performed

“Frequent”: regularly performed; generally an act that is required on a daily basis

“Continuous”: typically performed for the majority of an employee’s shift

Sitting for prolonged periods of time, frequently standing, walking distances up to one mile, bending, crouching, kneeling, reaching, occasionally lifting 25lbs, extensive typing, picking up and holding small objecting and otherwise using primarily the fingers rather than the entire hand. Employee is required to have visual acuity sufficient to perform activities such as preparing and analyzing data and figures; transcribing notes; viewing a computer terminal and extensive reading. Employee is required to have hearing sufficient to understand verbal instruction and answer telephones. Reliance Standard Life Insurance will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

All Reliance Standard Life Insurance employees are required to behave according to our core values:

We operate with honesty, transparency and trust.

We collaborate and communicate openly, free of politics and personal agendas.

We are empowered to achieve the company’s mission and hold ourselves accountable.

We solve problems and advance by challenging the status quo.

We care about each other and our communities.

We have fun.

The above description reflects the general details considered necessary to describe the principle responsibilities and functions of the job identified and shall not be construed as a detailed description of all the work requirements that may be inherent to this job.

• The expected hiring range for this position is $25.10 - $31.37 hourly for work performed in the primary location (Canandaigua, NY). This expected hiring range covers only base pay and excludes any other compensation components such as commissions or incentive awards. The successful candidate’s starting base pay will be based on several factors including work location, job-related skills, experience, qualifications, and market conditions. These ranges may be modified in the future.
• Work location may be flexible if approved by the Company.

What We Offer

At Reliance Matrix, we believe that fostering an inclusive culture allows us to realize more of our potential. And we can’t do this without our most important asset—you.

That is why we offer a competitive pay package and a range of benefits to help team members thrive in their financial, physical, and mental wellbeing.

Our Benefits:

• •An annual performance bonus for all team members
• •Generous 401(k) company match that is immediately vested
• •A choice of three medical plans (that include prescription drug coverage) to suit your unique needs. For High Deductible Health Plan enrollees, a company contribution to your Health Savings Account
• •Multiple options for dental and vision coverage
• •Company provided Life & Disability Insurance to ensure financial protection when you need it most
• •Family friendly benefits including Paid Parental Leave & Adoption Assistance
• •Hybrid work arrangements for eligible roles
• •Tuition Reimbursement and Continuing Professional Education
• •Paid Time Off – new hires start with at least 20 days of PTO per year in addition to nine company paid holidays. As you grow with us, your PTO may increase based on your level within the company and years of servic