Administer ADA claims by conducting eligibility reviews, making claim decisions, and managing leave administration. Duties include data gathering, communication with employees and physicians, and ensuring compliance with timeliness goals. The role involves analyzing transactions, resolving discrepancies, and working collaboratively to meet performance standards in claims processing.
Description and Requirements
Basic Function
- Administer ADA (Americans with Disability Act) standalone claims
- Complete eligibility decisions and review for entitlement, gather pertinent data when necessary, from employee, physicians office or employer through outgoing calls, email, fax or other supporting systems.
- Promptly review new ADA, evaluate against appropriate leave plans and make initial claim decision.
- Perform leave administration tasks as required, including recertification of health condition, intermittent claim tracking, RTW confirmation, return phone calls, etc.
- Update systems to accurately reflect leave status and ensure appropriate diary documentation exists
- Business recommended TAT to complete the activity is up to 5 business days to maintain compliance measures
- The position is expected to do absence management and adjudication on Federal, State and company leaves.
- Interact with claim specialist, claim support specialist, QA, Claims Unit Leader (stateside supervisors), employees, employers/customer and physician's office
Essential Functions:
- Analyze, validate and process transactions as per Desktop procedures (L3 & L4)
- Analyze and research all discrepancies
- Research & Investigate and resolve outstanding items
- Determine eligibility, entitlement and applicable plan provisions while meeting timeliness goals
- Clear and accurate written and verbal communication (Mix of scripted/unscripted) with employee, employer & stateside resources by email and outgoing calls
- Establish action plans for each file to bring claims to resolution
- Utilize internal and external specialty resources to maximize impact on each claim file
- Use PC programs to increase productivity and performance
- Ensure that the assigned targets are met in accordance with SLA, Performance Guarantee and Internal standards
- Ensure that the quality of transaction is in compliance with predefined parameters as defined by Process Excellence
- Work as a team member to meet office goals to obtain disability's vision while demonstrating core values and meeting key measures
- Ensure adherence to established attendance schedules
- Close visual activity - viewing a computer terminal and extensive reading
Any other essential function that may occur from time to time as directed by the Supervisor.
Primary Internal Interactions
- UM for the purpose of reporting performance, escalation handling, clarifying concerns, and seeking feedback and support
- Manager for the purpose of settling issues left unresolved by the AM and monthly evaluation of performance
- Subject Matter Expert for the purpose of work thread related issues and escalated transactions
- QCA for the purpose of feedback and internal Performance Guarantee quality audit team
- Trainers for the purpose of Pre-process and Process DCA training
- Disability Customer Advocates for escalation resolution
Primary External Interactions
- End customer to be contacted through emails/calls for information gathering/decision update
- Claims specialist & other Stateside Teams on emails/calls
- SME / Trainers at the client end for training
About MetLife
Recognized on Fortune magazine's list of the 2024 "World's Most Admired Companies" and Fortune World's 25 Best Workplaces™ for 2024, MetLife , through its subsidiaries and affiliates, is one of the world's leading financial services companies; providing insurance, annuities, employee benefits and asset management to individual and institutional customers. With operations in more than 40 markets, we hold leading positions in the United States, Latin America, Asia, Europe, and the Middle East.
Our purpose is simple - to help our colleagues, customers, communities, and the world at large create a more confident future. United by purpose and guided by empathy, we're inspired to transform the next century in financial services.
At MetLife, it's #AllTogetherPossible . Join us!
#BI-Hybrid
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