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Disability Claims Specialist - Remote

Company: Software Guidance and Assistance, Inc.
Location: Cary
Posted on: May 15, 2024

Job Description:

Software Guidance & Assistance, Inc., (SGA), is searching for a Disability Claims Specialist for a CONTRACT assignment with one of our premier Insurance Services clients for a Remote position.


  • Effectively manages with some level of oversight an assigned caseload of moderately complex claims including pending and ongoing/active reviews. The LTD CS will be evaluated for increases in their authority levels as they become more experienced in their decision-making and demonstrate consistency in meeting all key performance indicators.
  • Provides timely, balanced, and accurate claims reviews, documentation, and recommended decisions in a time sensitive and fast-paced environment and in accordance with state and department of insurance regulations.
  • Provides frequent, proactive verbal communication with our claimants and/or their representatives demonstrating empathy and active listening while providing clear updates, direction and explanations regarding the claim process, benefits, and other pertinent plan provisions. These calls are used to gather essential details regarding medical condition(s) and treatment, occupational demands, financial information, and any other information that may be pertinent to the evaluation of the claim. Once telephone calls are completed, you will be required to document the conversation within the claim file in a timely manner utilizing the appropriate level of detail and professional writing skills.
  • Interacts and communicates effectively with claimants, customers, attorneys, brokers, and family members during claim evaluations.
  • Compiles file documentation and correspondence requiring extensive policy and factual detail. Analyzes information to determine if additional information is needed to make a reasonable and logical claims determination based off the information available.
  • Collaborates with both external and internal resources, such as physicians, attorneys, clinical/vocational consultants as needed to gather data such as medical/occupational information in order to ensure reasonable, thorough decisions.
  • Clarifies and reconciles inconsistencies when gathering information during claim evaluations and collaborates with Fraud Waste and Abuse resources as needed.
  • Proficiently calculates monthly benefits due after elimination period, to include COLA, Social Security Offsets, and Rehab Return to Work benefits, and other non-routine payments.
  • Provides timely and detailed written communication during the claim evaluation process which outlines the status of the evaluation and/or claim determination.
  • ddresses and resolves escalated customer complaints in a timely and thorough manner. Identifies and refers appropriate matters to our appeals, complaint, or litigation support areas.
    Required Skills:
    • Bachelor's degree
    • Must have 3+ years of LTD/IDI Insurance Claims experience - required
    • Prior experience with independent judgement and decision making while relying on the available facts
    • Be able to demonstrate the use of critical thinking and analysis when reviewing the information
    • Creative problem-solving abilities and the ability to think outside the box
    • Excellent interpersonal and communication skills in both verbal and written form
    • Excellent customer service skills proven through internal and external customer interactions
    • Demonstrated conceptual thinking, risk management, ability to handle complex situations effectively
    • Organizational and time management skills

      SGA is a technology and resource solutions provider driven to stand out. We are a women-owned business. Our mission: to solve big IT problems with a more personal, boutique approach. Each year, we match consultants like you to more than 1,000 engagements. When we say let's work better together, we mean it. You'll join a diverse team built on these core values: customer service, employee development, and quality and integrity in everything we do. Be yourself, love what you do and find your passion at work. Please find us at .

      SGA is an Equal Opportunity Employer and does not discriminate on the basis of Race, Color, Sex, Sexual Orientation, Gender Identity, Religion, National Origin, Disability, Veteran Status, Age, Marital Status, Pregnancy, Genetic Information, or Other Legally Protected Status. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, and our services, programs, and activities. Please visit our company EEO page to request an accommodation or assistance regarding our policy.

Keywords: Software Guidance and Assistance, Inc., Cary , Disability Claims Specialist - Remote, Other , Cary, North Carolina

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