Welfare Department Senior Lead Claims & Appeal Associate

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 Funds welfare benefits (hospital medical dental vision hearing prescription Supplemental Medicare disability PFL vacation scholarship eligibility life insurance and accidental death and dismemberment) for over 20000 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 departments 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 plans determination.

Trains Welfare Department employees on standard operating procedures (SOPs)

Ensure compliance with federal state and company regulations and policies.

Knowledge Skills and Abilities

Bachelors 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

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 individuals 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 .

Salary and Benefits:

Salary Range: $72000- $83000

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.