Disability Claims Management Specialist 2

at  Pacific Blue Cross

ABOUT PACIFIC BLUE CROSS

Pacific Blue Cross (PBC) has been British Columbia’s leading benefits provider for over 80 years. We are an independent, not-for-profit society with strong roots in BC’s health care system. We provide health, dental, life, disability, and travel coverage to 1 in 3 British Columbians through employee group plans and individual plans.
We are fueled by a commitment to keep health care sustainable for all British Columbians. Through our PBC Health Foundation, we fund projects that improve health outcomes directly related to mental health and wellbeing as well as the prevention and/or management of chronic disease. We are interested in finding people who want to make a difference and who are looking to grow their career with us.

JOB SUMMARY

Under the general supervision of the Supervisor, Work & Wellness (W&W), the Disability Claims Management Specialist 2 provides the full range of professional disability and waiver of premium claims services to insured clients and Administrative Services Only (ASO) applicants undergoing review, and ensures claims are coordinated and managed within contractual terms and conditions of eligibility and coverage including 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; develops cost/benefit analyses; develops case management plans; coordinates settlements; coordinates referrals to internal stakeholders for rehabilitation; coordinates the use of external service providers; develops and implements return-to-work initiatives and conducts reviews of ongoing cases; responds to appeals for declined claims; manages claimant and client relationships; and, actively participates in conference calls with selected groups to build ongoing relationships.

DISABILITY CLAIMS ADJUDICATION, ASSESSMENT, INTERVENTION AND CASE MANAGEMENT

1. Provides the full range of professional disability and waiver of premium claims services to insured clients and ASO applicants undergoing review, and ensures claims are coordinated and managed within contractual terms, conditions of eligibility, and coverage by:

• reviewing, analyzing, and investigating claims and history/conditions of claimants to determine eligibility information from a variety of sources as well as requesting and documenting additional information as required.

• interpreting and applying contract wording, medical documentation, claims policies and procedures, statutory requirements and other guidelines affecting valuation and disposition of short- and long-term disability claims.

• identifying and following up on variances in policy and structure set up in the claims adjudication system or other deficiencies such as variances between policy provisions and eligibility.

• investigating pre-existing conditions and other policy exclusions to determine impact on eligibility and valuation
• conducting telephone interviews and/or communicating in writing with claimants, policy holders, employers, treatment providers, lawyers, brokers, third parties, and other stakeholders in the disability claims process to gather claims-related information, determine level of functionality, determine status of accommodation, return to work, and/or necessary intervention and case management services including independent medical evaluations and functional capacity evaluations, and probe further into circumstances giving rise to the claim through the application of professional interviewing protocols and documentation skills.
• 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 management to ensure claims-related decisions meet professional and quality standards, and communicating the final decision to claimants and employers.
• developing initial and ongoing 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.
• developing case management plans and early intervention including setting plan expectations and outcomes, preparing, and referring case files to external stakeholders for assessments and medical treatment and management such as clarifying objectives of the referral and coordinating return to work plans with the employer. Coordinating referrals to internal stakeholders for rehabilitation. May coordinate settlements for insured clients.
• coordinating and overseeing the services of treatment providers to facilitate recovery for disability claims.
• coordinating and overseeing, with internal stakeholders, the services of internal and external rehabilitation services.
• developing, implementing, and monitoring return-to-work initiatives including modified, accommodated, and graduated return-to-work programs, and taking required action if situations change.

• regularly reviewing high intervention short-term and long-term disability cases to facilitate treatment optimization and return-to-work planning through referrals to internal and external stakeholders as required.

• checking system-generated payment calculations for accuracy, processing gradual return-to-work earnings, performing manual calculations to determine a variety of benefit payment and adjustment amounts, overriding system limitations where required, and ensuring accurate coding of short- and long-term disability claims.

• identifying and calculating amounts for recovery where Canadian Pension Plan (CPP), Workers’ Compensation Board (WCB) benefits, other sources of income/benefits, motor vehicle accidents prior to 2019, 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 recovery.

• ensuring documentation and claim status is continually updated in the systems.

1. Responds to appeals for declined claims in accordance with established processes which may include requesting and analyzing new information from claimants and/or physicians, seeking further interpretations from W&W medical consultants, conducting reassessments of information on the claim file, and presenting cases to the Leadership Review Committee with rationale and recommendations for further consideration, or to maintain or overturn the original decision.
2. Maintains liaison with re-insurers when benefits exceed specified limits, completes complex case action plans including summaries, rationales, restrictions, and next steps. Refers claims to leadership team for review and concurrence prior to forwarding claims to re-insurers and escalates to leadership team if the re-insurer does not concur with the recommendation.

QUALIFICATIONS:

• High school graduation, or equivalent.
• Completion of a 1-year Disability Management Diploma (288 hours), or equivalent.
• Demonstrated proficiency in basic Word and Excel.
• 3 years of previous related experience in disability claims management with 2 years in a Disability Claims Specialist or Disability Claims Management Specialist 1 position, or equivalent.
• Demonstrated proficiency in disability claims management including assessment, oversight of interventions and claim resolution.
  If you’re excited about taking on this opportunity, we invite you to apply today and start the conversation with us about this position. Together we can create a healthier British Columbia through teamwork, exceptional service and accountability that will help improve sustainable healthcare.
  Please apply via our website this week at http://www.pbchbs.com/company/careers/While we thank all applicants for their interest, only short-listed candidates will be contacted.