Short Term Disability; STD Claims Examiner

RO Portland ME, 255 Gorham Rd 4th Fl, South Portland, ME 04106, USA

At One America, we deliver on promises when customers need us most. We believe the best way to serve our customers is to know that every individual, employee, family and business we work with has unique personal and financial goals. We keep our promises, so we can help them achieve their goals and realize their definition of financial success.

Job Summary

The STD Claims Examiner is responsible for contributing to the overall success of One America objectives by providing timely and accurate support to our client companies and the Claims department. This individual will be responsible for managing appropriate adjudication of short‑term disability claims in accordance with policy provisions. The STD Claims Examiner will initiate and facilitate case management as well as other ancillary services to assure optimum outcomes.

We are currently seeking Level I & II Representative experience.

• Promote a positive customer service image through prompt, accurate and courteous responses to customer information needs
• Consistently adhere to the documented workflow guidelines and established procedures.
• Maintain required levels of confidentiality
• Demonstrate competency in all modules of training program. Remain abreast of industry standards via internal/external continuing education
• Promptly and thoroughly investigate and evaluate claims within departmental and regulatory guidelines
• Interpret and administer contract provisions including, but not limited to, eligibility, covered weekly earnings, definition of Total Disability, verification of applicable offsets and pre‑existing investigations
• Calculate benefit and identify other income replacement benefits. Processes financial activities, including, but not limited to, payment adjustments, stop payments, voids and check reissues, other income adjustments, reimbursement checks, and final benefits. Processes over payments in accordance with established procedures
• Assist in the subrogation process to recover money from third parties
• Work in coordination with an LTD Examiner to ensure an appropriate transition from the STD claim to LTD
• Document claim file actions and telephone conversations appropriately
• Refer claim activity outside authority level to Supervisor/Manager for review
• Proactively communicate with claimants, policyholders and physicians to resolve investigations issues
• Establish, communicate and manage claimant and policyholder expectations
• Utilize most efficient means to obtain claim information
• Fully investigate all relevant claim issues, providing payment or denials promptly and in full compliance with departmental procedures and Unfair Claims Practice regulations
• Respond to customer service issues within required time frames
• Involve technical resources (Social Security Specialist, medical resources and vocational resources) at appropriate claim junctures
• Support relationships with technical resources to achieve appropriate outcomes
• Meet or exceed departmental service, quality and production objectives
• Collaborate with team members and management in identifying and implementing improvement opportunities. Informs Supervisor of any trends noted within specific client companies
• All other duties as assigned

• BA/BS or equivalent combination of education and experience
• 0‑2+ years of experience in managing Short Term Disability claims with first pay authority
• Ability to fluently speak and write Spanish a plus
• Excellent math and calculation skills
• Ability to analyze complex claim information
• Working knowledge of Microsoft Excel and Word
• High School Diploma required, or any combination of education and experience which would provide an equivalent background.

Salary Band: 3C

This selected candidate will be expected to work hybrid in Portland, ME. The candidate will also be expected to physically return to the office in CA, IN or ME as business needs dictate or for team‑building and collaboration.

If you are offered and accept this position, please be advised that One America Financial does not have any offices located in the State of New York and One America Financial associates are not…