MetLife

Position Location: 100% Virtual

Key Responsibilities: 

• Independently manage an assigned caseload of the most complex claims which consists of pending, ongoing/active and appeal reviews. 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 timely and detailed written communication during the claim evaluation process which outlines the status of the evaluation and/or claim determination and interacts and communicates effectively with claimants, customers, health care providers, 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. 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.
• Collaborates effectively with both external and internal resources, such as physicians, attorneys, vocational consultants and CPAs, 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 and addresses/resolves escalated customer complaints in a timely and thorough manner. Identifies and refers appropriate matters to our appeals, complaint, or litigation support areas.
• Serves as an extended leadership team member, participates in new hire onboarding including coaching, mentoring and development, providing direct support to Unit Leaders, and partners with the leadership team to meet project goals related to quality, timely claim outcomes, customer service and staff development and provide detailed, balanced feedback to leadership on individual, team, customer or site performance and offers solutions on opportunities identified.

Essential Business Experience and Technical Skills:

Required:

• 5+ years of LTD/IDI Insurance Claims experience with excellent customer service skills proven through internal and external customer interactions and prior experience with independent judgement and decision making while relying on the available facts/problem solving/critical thinking while having the ability to effectively manage multiple systems and technology resources/Organizational and time management skills.

 Preferred:

• Bachelor’s degree and knowledge of STD/FML, state leave laws, worker’s compensation, ERISA, and Social Security.

At MetLife, we’re leading the global transformation of an industry we’ve long defined. United in purpose, diverse in perspective, we’re dedicated to making a difference in the lives of our customers.