Job Description:
Location: USA, Remote
Job Summary
The LTD Claims Examiner II investigates, analyzes, and adjudicates long-term disability, voluntary disability, and waiver of premium claims in accordance with insurance policy provisions, internal procedures, and applicable regulations. The role involves reviewing medical and employment information, communicating with claimants and relevant parties, calculating benefit payments, maintaining accurate claim records, and independently managing a caseload of simple to complex claims while meeting quality, accuracy, and productivity standards.
Key Responsibilities
- Investigate disability claims by gathering information from claimants, employers, supervisors, physicians, and other relevant parties.
- Analyze claim documentation and make fair, accurate eligibility and payment decisions in accordance with policy provisions and applicable regulations.
- Manage and adjudicate a high volume of claims ranging from simple to complex.
- Identify changes in total disability definitions and investigate relevant claim circumstances.
- Review complex claims independently within established approval authority limits.
- Determine eligibility for waiver of premium benefits under applicable life insurance policies.
- Calculate disability benefits, including partial disability, residual disability, survivor benefits, and offsets for other income sources.
- Conduct pre-existing condition and contestability investigations when required.
- Consult appropriate medical and risk resources and refer claims to the correct risk level when necessary.
- Maintain accurate electronic claim data and supporting documentation.
- Manage an assigned caseload of approximately 60–80 claims independently.
- Provide timely, respectful, and accurate customer service while balancing competing priorities.
- Collaborate with colleagues and management to identify and implement process improvements.
Required Qualifications
- High school diploma or GED.
- At least 2 years of experience processing long-term disability claims.
- Understanding of claims management, critical thinking, analysis, and investigation techniques.
- Experience handling confidential or protected personal information.
- Knowledge of medical terminology.
- Strong mathematical and benefit-calculation skills.
- Ability to manage complex claims independently and meet productivity and quality standards.
- Strong communication and customer service skills.
Preferred Qualifications
- Associate degree in Business, Finance, Social Work, or Human Resources.
- Level I LOMA designation.