LTD Claims Examiner Sr.

Vets Hired; New York (NY); On-site; USD 85,000 - 110,000; Full time

Job summary

Vets Hired is recruiting a Senior Long-Term Disability Claims Examiner to investigate, adjudicate, and resolve complex LTD, voluntary disability, and waiver of premium claims. You will work independently, mentor peers, and contribute to investigations and process improvements.

The role requires deep knowledge of disability claims, strong analytical skills, and the ability to manage a high-volume caseload while delivering accurate determinations and excellent customer service.

Qualifications

• High school diploma or GED required.
• At least 5 years of experience processing long-term disability claims.
• Advanced knowledge of claim management, analysis, investigation, and critical thinking.
• Experience handling confidential and protected information.
• Thorough knowledge of medical terminology.
• Strong mathematical and benefit-calculation skills.
• Ability to manage complex claims independently while meeting productivity and quality standards.
• Strong communication, customer service, and problem-solving skills.

Responsibilities

• Investigate complex disability claims by gathering information from claimants, employers, treating physicians, and other relevant parties.
• Adjudicate claims accurately and fairly in accordance with policy provisions, internal procedures, and state and federal regulations.
• Manage a high-volume caseload of approximately 60-80 complex claims independently.
• Evaluate changes in total disability definitions, including any-occupation provisions.
• Make independent claim decisions within established approval authority limits.
• Determine eligibility for waiver of premium benefits under applicable life insurance policies.
• Conduct detailed pre-existing condition and contestability investigations when necessary.
• Calculate benefits, including partial disability, residual disability, survivor benefits, and offsets from other income sources.
• Consult appropriate medical and risk resources and refer claims to the correct risk level.
• Maintain accurate electronic claim records and supporting documentation.
• Provide prompt, professional, and accurate customer service while managing competing priorities.
• Mentor and train newer claims examiners and assist with claim-related projects.
• Support management with presentations, complaint investigations, regulatory inquiries, and executive complaints.
• Identify trends, training needs, and opportunities to improve claims processes.

Skills

Claim management

Investigation

Analysis

Critical thinking

Confidential information handling

Medical terminology

Communication

Customer service

Problem solving

Time management

Education

High school diploma or GED

Associate degree

Job description

Job Summary

The Senior Long-Term Disability (LTD) Claims Examiner investigates, analyzes, and adjudicates complex long-term disability, voluntary disability, and waiver of premium claims. This role independently makes claim determinations based on policy provisions, available evidence, and applicable regulations. The position also provides subject matter expertise, mentors newer examiners, and supports claim-related investigations, training, and process improvements.

Key Responsibilities

• Investigate complex disability claims by gathering information from claimants, employers, treating physicians, and other relevant parties.
• Adjudicate claims accurately and fairly in accordance with policy provisions, internal procedures, and state and federal regulations.
• Manage a high-volume caseload of approximately 60-80 complex claims independently.
• Evaluate changes in total disability definitions, including any-occupation provisions.
• Make independent claim decisions within established approval authority limits.
• Determine eligibility for waiver of premium benefits under applicable life insurance policies.
• Conduct detailed pre-existing condition and contestability investigations when necessary.
• Calculate benefits, including partial disability, residual disability, survivor benefits, and offsets from other income sources.
• Consult appropriate medical and risk resources and refer claims to the correct risk level.
• Maintain accurate electronic claim records and supporting documentation.
• Provide prompt, professional, and accurate customer service while managing competing priorities.
• Mentor and train newer claims examiners and assist with claim-related projects.
• Support management with presentations, complaint investigations, regulatory inquiries, and executive complaints.
• Identify trends, training needs, and opportunities to improve claims processes.

Required Qualifications

• High school diploma or GED.
• At least 5 years of experience processing long-term disability claims.
• Advanced knowledge of claim management, analysis, investigation, and critical thinking.
• Experience handling confidential and protected information.
• Thorough knowledge of medical terminology.
• Strong mathematical and benefit-calculation skills.
• Ability to manage complex claims independently while meeting productivity and quality standards.
• Strong communication, customer service, and problem-solving skills.

Preferred Qualifications

• Associate degree in Business, Finance, Social Work, or Human Resources.
• Level I LOMA designation.