Under the general supervision of the Disability Supervisor, provides the full range of professional disability, life claims, critical illness, and waiver of premium claims services to insured clients and applicants undergoing review. Ensures claims are coordinated and managed within contractual terms and conditions of eligibility and coverage including organizing, reviewing, analyzing and investigating claims information from a variety of sources, determining adjudication, assessment and intervention actions affecting short- and long-term disability claims management, payment and duration including those of a complex nature. Completes telephone interviews with claimants, policy holders and employers, and communicates with all stakeholders during the claims process. Develops case management plans for vocational and medical rehabilitation, develops cost/benefit analyses and coordinates the use of external service providers. Develops and implements return to work initiatives and conducts regular reviews of ongoing cases. Responds to first level appeals for declined claims. Actively participates in conference calls with selected groups to build ongoing relationships.
- A) BC Life Disability Claims Adjudication, Assessment, Intervention and Case Management
1.Provides the full range of professional disability, life claims, critical illness, and waiver of premium claims services to insured clients and applicants undergoing review, and ensures claims are coordinated and managed within contractual terms and conditions of eligibility and coverage by:
- organizing, reviewing, analyzing, and investigating claims and eligibility information from a variety of sources.
- interpreting and applying contract wording, medical reports, claims policies and procedures, statutory requirements and other guidelines affecting short- and long-term disability claims management, payment and duration, including those of a complex nature.
- identifying and following up on variances in policy and structure set up in system or other deficiencies such as variances between policy provisions and eligibility.
- investigating pre-existing limitations and other policy exclusions to determine impact on eligibility and valuation.
- completing telephone interviews with claimants, policy holders and employers to gather claims-related information, determine level of functionality and probe further into circumstances giving rise to the claim through the application of professional interviewing techniques and documentation skills:
- through verbal and written means, communicating on an ongoing basis with other stakeholders including a variety of treatment practitioners, doctors, lawyers, brokers, third parties and others in the disability claims process to verify claims information, determine status of accommodation, return to work, and/or necessary intervention and case management services including independent medical evaluations and functional capacity evaluations;
- deciding on the acceptance or denial of the claim and other decision outcomes, preparing and documenting the rationale for the decision, making internal round table presentations to colleagues and managers to ensure claims-related decisions meet professional and quality standards, and communicating the final decision to claimants to ensure understanding while diffusing a wide range of emotional impacts;
- developing case management plans for vocational and medical rehabilitation, and early intervention including setting plan expectations and outcomes, preparing case files for referral to external specialists including clarifying objectives of the referral, coordinating return to work plans with the employer as well as all required flight, travel and accommodation arrangements;
- developing initial cost/benefit analyses for intervention options and case management plans to identify the most cost-effective approach to managing disability claims without compromising on contractual obligations; estimates probable and potential outcomes and factors those outcomes into the development and costing of the case management plan;
- coordinating the services of internal and external rehabilitation and medical management and treatment service providers;
- developing, implementing and monitoring return to work initiatives including modified, accommodated and graduated return to work programs; takes required action if situations change;
- regularly reviewing complex short term and long term disability cases to implement, monitor and adjust case management options to facilitate earlier return to work such as work re-conditioning, cognitive behaviour training or employer-initiated changes in workplace conditions;
- checking system-generated payment calculations for accuracy, performing manual calculations to determine a variety of benefit payment and adjustment amounts, overriding system limitations where manual calculations of benefits owing, offsets and taxes are required, and ensuring accurate coding of system fields used to generate required reserves for pending long term disability cases;
- identifying and calculating amounts for recovery where CPP, WCB benefits or earlier than expected return to work have or may result in overpayment; communicates recovery amounts and expectations for repayment to all affected parties, and follows up to ensure collection.
- Responds to first level appeals for declined claims by reviewing and analyzing new information provided by claimants and/or physicians, seeking further interpretations from BC Life medical consultants, conducting reassessments of information on the claim file, and presenting cases to the Disability Claims Review Committee with rationale and recommendations for further consideration or to validate the original decision.
Customer, Client and Member Service
- In consultation with the Disability Supervisor, actively participates in regular conference calls with selected groups to build trust, facilitate relationship building, answer questions on case management approaches and practices, and to provide input on claims trends and activities for Underwriting’s use in conducting renewal reviews. May attend on site visits with clients to gain exposure to employer or industry environments and working conditions.
- Plans the content of and composes a variety of written correspondence and reports which adhere to the established standards of business English. internal style guidelines, privacy legislation and confidentiality considerations.
- Manages claimant and client relationships by keeping employers, third party administrators, union and trustee representatives informed of all decisions, and providing timely responses to inquiries. Escalates non-BC Life concerns and inquiries to appropriate area.
General Team and Department Support
- Maintains up to date knowledge of disability management best practices, policies and procedures, legal compliance issues, system requirements and other information related to the application of disability management services through round tables and continuous learning initiatives including internal learning activities, presentations, workshops and team podcasts.
- On a one-to-one basis, supports other team members and new employees by demonstrating the execution of specific tasks and duties, and sharing knowledge and experience on request.
- Performs other assigned duties related to disability claims management services which do not affect the rating of the job.
- High school graduation or equivalent
- Completion of Certificate Program in Disability Management (450 hours) through Grant MacEwan College (distance learning) or equivalent
- Demonstrated proficiency in basic Word and Excel
- Minimum of three years previous related experience in disability claims adjudication with at least one year in any Disability Adjudication Specialist 1 or 2 role (or equivalent) with demonstrated experience in claims assessment up to the point of intervention
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DGA Careers has been proudly serving the Canadian insurance industry for over 35 years, specializing in providing insurance recruiting services to major insurers, insurance brokerage firms and independent adjusting firms. With offices in Toronto, Vancouver, Montreal, Edmonton, and Calgary, DGA Careers is well positioned to conduct searches with a national scope. Our unrivalled professional network across Canada provides us with the ability to reach vital key influencers and passive candidates nationally.
Interested candidates please contact Kanak Deshpande at 778-383-9790 Ext.101 or forward your resume in confidence to email@example.com. If you are working with another DGA recruiter, feel free to ask them about this position.