Welfare Department Senior Lead Claims & Appeal Associate at N Y C District Council Carpenters Welfare Fund

SENIOR LEAD CLAIMS & APPEALS ASSOCIATE

Department: Welfare

Position Reports to: Welfare Manager

FLSA Status: Exempt

Direct Reports: None

The Senior Lead Claims & Appeals Associate assists in overseeing the administration of the Fund’s welfare benefits (hospital, medical, dental, vision, hearing, prescription, Supplemental Medicare, disability, PFL, vacation, scholarship, eligibility, life insurance and accidental death and dismemberment) for over 20,000 members. Evaluates appeals and grievances to facilitate the accurate administration of benefits and clinical policy; ensure compliance of the appeal and grievance process with all regulatory requirements and standards. Conducts thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities. Serves as a liaison between internal departments, medical groups, and insurance vendors to ensure timely resolution of cases. Implements workflow procedures that provide support in escalated situations and the department’s overall workflow. Serves as subject matter expert on all welfare benefits and department processes.

Essential Job Functions:

· Participates in the administration of member benefits

· Provides direction to staff responsible for the processing of member and retiree benefit transactions

· Assists and completes the necessary research to resolve member service issues,

· Assists in the development of internal procedures; provides guidance and training for staff to ensure timely and accurate updates of member information and benefits records

· Serves as subject matter expert for Welfare Claims processing

· Comprehensively reviews and evaluates appeal and grievance requests to identify and classify member and

provider appeals.

· Consults with the Legal Department to clarify legal ramifications around complex appeals.

· Accurately prepares cases for medical and administrative review by detailing the findings of the investigation for

consideration in the plan’s determination.

· Trains Welfare Department employees on standard operating procedures (SOP’s)

· Ensure compliance with federal, state, and company regulations and policies.

Knowledge, Skills and Abilities

· Bachelor’s Degree or equivalent experience

· 5 years’ experience in health and welfare benefit plan administration preferably in a multi-employer environment

· 1-2 years’ management experience or experience supervising work of others

· Extensive knowledge of medical claims and benefit administration procedures

· Excellent verbal and written communication skills

· Superior organization skills

· Demonstrated ability to effectively manage multiple priorities

· Excellent problem solving and analytical skills required

· Ability to work under pressure and deliver complete, accurate, and timely results required.

Apply: To apply, please send resume to [email protected]

EEO Statement

The NYCDCC Benefit Funds are committed to a policy of Equal Employment Opportunity and will not discriminate against an applicant or employee on the basis of race, creed, religion, color, national origin, ancestry, alienage, pregnancy, disability, age, uniform service member status, veteran status, marital status, caregiver status, familial status, status as a victim of domestic violence, sexual violence or stalking, membership in a domestic partnership, sex, gender (including gender identity, gender expression or status as a transgender person), genetic information, sexual orientation (including an individual’s actual or perceived romantic, physical or sexual attraction to other persons, or lack thereof, on the basis of gender), sexual and reproductive health decisions, or on any other characteristic protected by applicable federal, state, or local law.

If reasonable accommodation is needed to participate in the job application or interview process, please contact Luan Delpeche at (212) 366-7519.

Salary and Benefits:

Salary Range: $72,000- $83,000

The rate of pay offered will be dependent upon candidates’ relevant skills, education, and experience. The NYCDCC Benefit Funds offer a generous and competitive package.