Claims Adjudicator II - Short Term Disability

UNITE HERE HEALTH serves 190,000+ workers and their families in the hospitality and gaming industry nationwide. Our desire to be innovative and progressive drives us to develop impactful programs and benefits designed to engage our participants in managing their own health and healthcare. Our vision is exciting and challenging. Please read on to learn more about this great opportunity!

The purpose of this position is to receive, examine, verify and input submitted disability claim data, determine eligibility status, and review and adjudicate disability claims within established timeframes. This includes but is not limited to all functions related to short term disability adjudication, payment adjustments, generating inventory and payment reports as well as handling member, provider, employer, health promoter and other interdepartmental inquiries.

This individual is responsible for analyzing plan documents, examining submitted claim and medical documentation and determining the need for additional information from members, employers, providers and Fund staff. This position utilizes multiple systems in order to perform the day-to-day functions of processing disability claims, identifying trends, and conducting analysis to determine opportunities for process improvement. This individual must possess excellent communication and organizational skills and the ability to work independently.

Essential Job Functions And Duties

• Reviews disability claims for completeness and determines the need for additional information or documentation from participants, employers, providers and other insurance carriers
• Verifies participant/dependent eligibility & investigates discrepancies
• Interprets the plan benefits from the Summary Plan Description (SPD)/Plan Documents
• Evaluates diagnoses, procedures, services, and other submitted data to determine the need for further investigation in relation to benefit requirements, accuracy of the disability claim filed, and the appropriateness, frequency or duration of care rendered
• Calculates and requests overpayment refunds, maintains corresponding files and performs follow-up actions
• Responsible for review, research and response to all inquiries, urgent requests and complaints received in the disability mailbox from internal and external customers within the established metric
• Processes Short Term Disability claims according to established metrics
• Verbal and written communication with providers, employers, members and various UHH staff
• Set goals and ensure quality measurements are met
• Obtains, reviews, and prepares necessary documentation for medical review
• Generates, reviews, and distributes daily, weekly, monthly, quarterly and annual reports and adjust disability payments if applicable
• Identifies areas for process improvement and makes recommendations to management
• Acts as a subject matter expert providing support to Fund staff
• Research & process disability check inquiries, including tracking/stop payments/check reissues
• Sets goals and achieve measurable results
• Contributes ideas to plans and achieving department goals
• Demonstrates the Fund’s Diversity and Inclusion (D&I) principles in their conduct at work and contributes to a safe inclusive culture with equitable opportunities for success and career growth
• Exemplifies the Fund’s BETTER Values in contributing to a respectful, trusting, and engaged culture of diversity and inclusion
• Performs other duties as assigned within the scope of responsibilities and requirements of the job
• Performs Essential Job Functions and Duties with or without reasonable accommodation
  
  

Essential Qualifications

Years of Experience and Knowledge

• 3 ~ 5 years of direct experience minimum in a /disability claim adjudication environment, or 3 years in health care or insurance environment
• Working knowledge and experience in interpretation of benefit plans, including an understanding of limitations, exclusions, and schedule of benefits
• Working knowledge and experience in short term disability, and its related processes
• Experience with eligibility verification preferred
• Experience with medical terminology preferred
  
  

Education, Licenses, and Certifications

• High School Diploma or GED
  
  

Skills And Abilities

• Intermediate level Microsoft Office skills (PowerPoint, Word, Outlook)
• Intermediate level Microsoft Excel skills
• Intermediate level system(s) skills in Javelina, Vitech, MDG, or other similar system preferred
• Excellent interpersonal, written and verbal communication skills
• Excellent time management, organizational and problem-solving skills, multi-tasking, and critical thinking skills
• Ability to demonstrate good judgement
• Ability to work independently with minimal supervision in a fast-paced environment
• Intermediate level knowledge of medical terms, conditions, and procedures
• Customer service
  
  

Salary range for this position: Hourly $20.31 - $24.92. Actual base salary may vary based upon, but not limited to: relevant experience, qualifications, expertise, certifications, licenses, education or equivalent work experience, time in role, peer and market data, prior performance, business sector, and geographic location.

Work Schedule (may vary to meet business needs): Monday~Friday, 7.5 hours per day (37.5 hours per week) as a hybrid work-from-home arrangement.

We reward great work with great benefits, including but not limited to: Medical, Dental, Vision, Paid Time-Off (PTO), Paid Holidays, 401(k), Pension, Short- & Long-term Disability, Life, AD&D, Flexible Spending Accounts (healthcare & dependent care), Commuter Transit, Tuition Assistance, and Employee Assistance Program (EAP).