Claims Examiner
2 months ago
About Pacific Blue Cross
Pacific Blue Cross is a leading provider of health, dental, life, disability, and travel coverage to individuals and groups in British Columbia. We are committed to keeping healthcare sustainable for all British Columbians.
Job Summary
We are seeking a highly skilled Disability Claims Management Specialist to join our team. As a Disability Claims Management Specialist, you will be responsible for providing professional disability and waiver of premium claims services to insured clients and Administrative Services Only (ASO) applicants. You will ensure that claims are coordinated and managed within contractual terms and conditions of eligibility and coverage.
Key Responsibilities
- Review, analyze, and investigate claims and history/conditions of claimants to determine eligibility information from a variety of sources.
- Interpret and apply contract wording, medical documentation, claims policies and procedures, statutory requirements, and other guidelines affecting valuation and disposition of short- and long-term disability claims.
- Identify and follow up on variances in policy and structure set up in the claims adjudication system or other deficiencies such as variances between policy provisions and eligibility.
- Investigate pre-existing conditions and other policy exclusions to determine impact on eligibility and valuation.
- Conduct telephone interviews and/or communicate in writing with claimants, policy holders, employers, treatment providers, lawyers, brokers, third parties, and other stakeholders in the disability claims process to gather claims-related information.
- Decide on the acceptance or denial of the claim and other decision outcomes, preparing and documenting the rationale for the decision.
- Develop initial and ongoing cost-benefit analyses for intervention options and case management plans to identify the most cost-effective approach to managing disability claims.
- Develop case management plans and early intervention, including setting plan expectations and outcomes, preparing and referring case files to external stakeholders for assessments and medical treatment and management.
- Coordinate and oversee the services of treatment providers to facilitate recovery for disability claims.
- Coordinate and oversee, with internal stakeholders, the services of internal and external rehabilitation services.
- Develop, implement, and monitor return-to-work initiatives, including modified, accommodated, and graduated return-to-work programs.
- Regularly review high intervention short-term and long-term disability cases to facilitate treatment optimization and return-to-work planning.
- Check system-generated payment calculations for accuracy, process gradual return-to-work earnings, and perform manual calculations to determine benefit payment and adjustment amounts.
- Identify and calculate amounts for recovery where Canadian Pension Plan (CPP), Workers' Compensation Board (WCB) benefits, or other sources of income/benefits have or may result in overpayment.
- Ensure documentation and claim status is continually updated in the systems.
Customer, Client, and Member Service
- Plan the content of and compose a variety of written correspondence and reports that adhere to established standards of business communications, internal style guidelines, privacy legislation, and confidentiality considerations.
- Manage claimant and client relationships by keeping employers, third-party administrators, union, and trustee representatives informed of all decisions and providing timely responses to inquiries.
- Identify and escalate non-W&W concerns and inquiries to appropriate areas within Pacific Blue Cross or other Blue Crosses.
- Participate in conference calls with selected groups to build trust, facilitate relationship building, answer questions, and provide input on claims trends.
General Team and Department Support
- Maintain up-to-date knowledge of disability management best practices, policies, and procedures, legal compliance issues, system requirements, and other information related to the application of disability management services.
- Support other team members and new employees by demonstrating the execution of specific tasks and duties and sharing knowledge and experience on request.
- Perform other assigned duties related to disability claims management, adjudication, and administration services that do not affect the rating of the job.
Qualifications
- High school graduation or equivalent.
- Completion of a 1-year Disability Management Diploma (288 hours) or equivalent.
- Demonstrated proficiency in basic Word and Excel.
- 3 years of previous related experience in disability claims management with 2 years in a Disability Claims Specialist or Disability Claims Management Specialist 1 position or equivalent.
- Demonstrated proficiency in disability claims management, including assessment, oversight of interventions, and claim resolution.
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