STD/Absence Claims Case Manager I

About this role

The STD/Absence Claims Case Manager I (CM) is responsible for adjudicating and medically managing Short Term and Absence claims involving specific diagnoses or leave types that tend to resolve quickly. The CM will work with employers, employees, and health care providers to administer Short Term disability in conjunction with other paid or unpaid leaves covered by Guardian, including Family and Medical Leave Act (FMLA), State Paid Medical Leave, and/or State Paid Disability. The CM will manage the claim according to the plan provisions, state and federal guidelines, and established protocols. This role requires sound judgment, critical thinking, and problem-solving skills to work independently, interpret contract provisions, analyze medical and claim information, and administer benefits through the appropriate claim duration or return to work. The CM is responsible for meeting key service deliverables such as turnaround times, quality assurance, and overall customer experience.

This position utilizes analytical reasoning, problem solving, adaptability, and strong written and verbal communication skills to ensure timely and appropriate absence and disability claim decisions while providing superior customer service to all internal and external customers. This position requires consistent and effective claim management skills, resilience in a fast-paced environment, and the ability to adapt as claim circumstances, priorities, or information change.

Candidate Responsibilities • Effectively understand contract language and plan design for group disability • Communicate claim status and decisions via telephone and in writing  • Initiate communications to claimant, physician, and planholder to assess and facilitate job accommodation opportunities • Proactive outreaches to claimants, planholders, and physicians via telephone for information needed for initial and ongoing claim management (e.g. current earnings, other income benefits, medical information, etc.); notifies claimants when claims are pended for missing information • Proactively identify claim issues, develop and execute a well-reasoned plan of action for pending and ongoing disability claims, and adjust strategies as new information becomes available. Utilize, manage, and direct appropriate resources to support timely and accurate benefit determination for internal and external customers in accordance with policy provisions, regulatory requirements, internal standards, and customer service expectations. • Apply critical thinking to investigate, analyze, and synthesize claim information, contract provisions, medical documentation, and regulatory requirements to determine coverage, benefit eligibility, and appropriate claim outcomes. • Demonstrate adaptability and resilience by effectively managing shifting priorities, changing claim circumstances, and time-sensitive decisions in a fast-paced environment. • Determine if claimants meet the definition of disability as defined in the contract by reviewing occupational requirements, analyzing medical information, identifying gaps or inconsistencies, and applying sound judgment to reach appropriate claim decisions. • Review, validate, and refine AI-generated claim recommendations, data extractions, and draft correspondence, applying professional judgment before finalizing decisions or communications. • Verify the accuracy and completeness of AI-assembled claim files and AI-flagged discrepancies, ensuring quality, regulatory compliance, and audit-readiness of claim documentation. • Establish, document and execute claim action plan and recommended path including return to active work at claimant’s own job • Determine Insured Earnings by reviewing payroll information from the planholder and calculate payable benefits according to plan provisions, with strong attention to accuracy, detail, and applicable offsets. • Follow all claim management procedures and facilitate potential return to work and job accommodation opportunities when applicable • Utilize claim management resources such as MDA (Medical Disability Guidelines) and other disability tools to assist with appropriate durational disability • Assess claim when other sources of income are received (e.g., social security, state disability, etc.,) to ensure accurate offsets are applied and recalculate benefits, as needed, to determine under/overpayments.   Proactively work with claimants to recover overpayments in full or negotiate monthly installments according to established protocols • Assess claim for restrictions and limitations to establish appropriate partnership with PRT • Remain composed, resourceful, and solutions-oriented when resolving routine claim challenges, addressing missing information, and determining appropriate next steps.

Reporting Relationship: This position reports to a Team Leader, STD/Absence.

Functional Skills • Outstanding customer service • Strong critical thinking, analytical reasoning, and information ability to assess claim, medical, payroll, and contract information accurately. • Ability to identify issues, evaluate options, and determine appropriate next steps with accuracy, timeliness, and customer focus • Strong math aptitude • Ability to manage multiple priorities and meet departmental turnaround times • Demonstrated independent problem solving, sound judgment, and decision-making ability within established procedures and service expectationAbility to clearly communicate claim decisions and contract language verbally and in written correspondence • Ability to multi-task, balance goals, prioritize effectively, and adapt to shifting business or claim priorities • Resilience and adaptability in a high-volume, fast-paced claim environment • Ability to work independently and within a highly collaborative team environment • Read and interpret medical information • Strong skillset in Microsoft Windows applications (e.g., Microsoft Word, Excel, Outlook) with AI/Co-Pilot Prompting Skills preferred • Effectiv

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