Claims Examiner 1

Job Responsibilities and Requirements

KEY RESPONSIBILITIES

*other duties as assigned*

The Claims Examiner I obtains and analyzes data for thorough, fair, objective, and timely processing of New York State statutory 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 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.
• Experience with Microsoft Office
• Work experience in decision-making and information analysis.
• 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.
• Meet and exceed production, attendance, quality and service
• Ability to organize work, manage time and follow through
• Availability to work overtime when required

Ability to Travel: None

PHYSICAL REQUIREMENTS

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 Matrix will provide qualified employees with a reasonable accommodation in accordance with applicable law.

CORE VALUES

• Collaboration
• Compassion
• Empowerment
• Integrity
• 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 $22.41 - $28.02 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 service. 
• Volunteer days, community partnerships, and Employee Assistance Program
• Ability to connect with colleagues around the country through our Employee Resource Group program

Our Values:

• Integrity
• Empowerment
• Compassion
• Collaboration
• Fun

EEO Statement

Reliance Matrix is an equal opportunity employer. We adhere to a policy of making employment decisions without regard to race, color, religion, sex, national origin, citizenship, age or disability, or any other classification or characteristic protected by federal or state law or regulation. We assure you that your opportunity for employment depends solely on your qualifications.

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