Your Name

• Evaluates treatment plans against individual goals and healthcare standards.
• Informally mentored new case managers and service coordinators, answering questions, offering opportunities to shadow and observe and explaining basic information about company procedures.
• Work closely with manager to ensure all performance guarantees are captured timely.
• Interact with team as initial point of contact for all questions on various subject matters.
• Serve as initial point of contact for attendance when manager is out of office.
• Interacts with Account executive to ensure all claims are processed according to plan statute.
• Address Social Security Overpayment payment letters as identified by our financial department.
• Maintain a current case load of ongoing claims with special emphasis on social security updates

● Independently reviews and interprets long term disability plan provisions and/or documents to determine claim liability.

Independently manages risk and resources on complex claims

● Consults and reviews clinical information with nurses and Medical Directors to establish the appropriate length of certification given contractual provisions and regulatory requirements.

● Ensures appropriate and detailed claim documentation to meet risk management, regulatory and accreditation requirements.

● Ensures liability is accurately established by maintaining accurate claims data and identifying applicable policy provisions, and claim offsets.

● Complies with all applicable state and federal laws and regulations, and Broadspire policy and procedure.

● Utilize Vocational Rehab, IME and Peer to Peer reviews for complex claim decisions.

● Communicate in writing with claimants, employer and account executives regarding claim and plan status.

• Referred clients to appropriate team members, community agencies and organizations to meet treatment needs.
• Independently reviews and interprets long term disability plan provisions and/or documents to determine claim liability.

● Independently manages risk and resources on moderately complex claims.

● Develops implements and revises comprehensive disability benefit management strategy based on factors such as claimant’s medical condition, vocational options, applicable policy provisions and limitations, actual or potential offsets, etc.

● Determines appropriate utilization of resources such as clinical, vocational rehabilitation, behavioral health, peer to peer review, referral to Complex Claim Investigation, social security vendors, etc.

● Works with claimants, treatment providers including physicians and therapists, policyholders, and/or attorneys to update claim management strategy as appropriate.

● Works with attorneys and insurance carriers regarding 3rd party litigation and/or subrogation issues.

● Effectively utilizes risk management tools to determine appropriate length of certification and timing of referrals for other income offset opportunities.

● Consults and reviews clinical information with nurses and Medical Directors to establish the appropriate length of certification given contractual provisions and regulatory requirements.

● Independently identifies claims that are appropriate for lump sum payout based on ethical and financially sound business practices.

● Ensures appropriate and detailed claim documentation to meet risk management, regulatory and accreditation requirements.

● Ensures reserve liability is accurately established by maintaining accurate claims data and identifying applicable policy provisions, and claim offsets.

● Complies with all applicable state and federal laws and regulations, and Aetna policy and procedure.

● Reviews and determines preliminary legal decisions and gathers information for response to department of insurance complaints.

● Gathers information and drafts response to department of insurance complaints or inquiries.

● Mentored new case managers after training

● Verifies Short Term Disability coverage.

● Initiate new claims.

● Case manage claim from initiation through closure or transition to long term disability.

● Evaluates information received, calculates, adjusts and pays benefits according to plan / state provision.

● Identifies other income sources and applies offsets appropriately.

● Communicates with and educates employees, employers, and physicians to set appropriate expectations both verbally and in writing.

● Documents claim decisions/actions.

● Enters data into appropriate claim processing systems.

● Utilize ICD-10, HCPCS, and CPT coding.

● Mentored new STD case managers on the floor