LTD Case Manager | Torchora

🎯 Role Definition

At its core, the LTD Case Manager role is a blend of analytical investigation and compassionate support. This professional serves as the primary point of contact for individuals on long-term disability leave, guiding them through the complexities of their claim. The Case Manager is responsible for the full lifecycle of a disability claim, from the initial eligibility assessment to ongoing management and, ultimately, resolution. This involves a meticulous evaluation of medical information, policy terms, and vocational factors to make fair and accurate claim decisions. Success in this position hinges on a unique ability to balance analytical rigor with genuine empathy, ensuring claimants feel supported while upholding the integrity of the disability policy and regulatory standards. They are the pivotal link between the claimant, medical providers, and employers, orchestrating a path toward recovery and a potential return to work.

📈 Career Progression

Typical Career Path

Entry Point From:

Disability Claims Examiner (Short-Term or Long-Term)
Vocational Rehabilitation Specialist
Registered Nurse (RN) with a background in case management or occupational health
Claims Assistant or Associate

Advancement To:

Senior LTD Case Manager or Complex Claims Specialist
Claims Team Lead or Supervisor
Claims Manager or Director
Appeals Specialist or Litigation Consultant
Quality Assurance Analyst or Trainer

Lateral Moves:

Short-Term Disability (STD) Case Manager
Life Insurance Claims Analyst
Workers' Compensation Case Manager
Vocational Consultant within an insurance carrier

Core Responsibilities

Primary Functions

Proactively manage a caseload of complex long-term disability claims, ensuring timely and accurate adjudication from initial review through to final resolution in accordance with policy provisions.
Conduct thorough and objective investigations of claims by gathering and analyzing all necessary data, including medical records, vocational information, and policy details.
Interpret and apply intricate insurance policy language and provisions to determine claim eligibility, benefit calculations, and ongoing liability.
Develop comprehensive, claimant-centered case management plans that include return-to-work strategies, rehabilitation opportunities, and coordination with healthcare providers.
Serve as the primary liaison for claimants, communicating claim decisions, rationale, and next steps with clarity, empathy, and professionalism.
Initiate and maintain consistent communication with policyholders, medical professionals, and other stakeholders to facilitate the claims process and obtain required information.
Critically evaluate medical information, including physician's statements, therapy notes, and diagnostic results, to assess the claimant's functional abilities and limitations.
Partner with in-house resources such as medical directors, vocational consultants, and legal counsel to assess complex claim scenarios and ensure sound decision-making.
Calculate and authorize timely and accurate benefit payments, including handling offsets for other income sources like Social Security Disability Insurance (SSDI).
Document all claim-related activities, communications, and decisions with a high degree of accuracy and detail within the claims management system.
Identify and pursue SSDI reimbursement opportunities by assisting claimants with their applications and managing the process with third-party vendors.
Evaluate and implement early intervention and rehabilitation strategies to support a claimant's recovery and facilitate a safe and timely return to productive employment.
Manage claim appeals by conducting a full re-evaluation of the claim file and preparing a detailed response outlining the final decision.
Ensure all claim handling practices are in strict compliance with federal regulations (such as ERISA), state insurance laws, and internal company standards.
Proactively identify and refer claims with potential for misrepresentation or fraud to the Special Investigations Unit (SIU) for further review.
Conduct detailed functional ability interviews with claimants to gain a clear understanding of their daily activities, job duties, and perceived barriers to returning to work.
Negotiate and resolve disputed claims through effective communication and conflict resolution techniques, potentially averting litigation.
Prepare and maintain organized, well-documented claim files that can withstand audits and legal scrutiny.
Collaborate with the employer (policyholder) to understand the claimant's specific job duties and explore possibilities for workplace accommodations.
Stay current on evolving case law, medical trends, and regulatory changes impacting long-term disability claim management.

Secondary Functions

Mentor and provide guidance to junior case managers or new team members on complex files and best practices.
Participate in departmental projects and initiatives aimed at improving claim processes, workflows, and customer service outcomes.
Contribute to team meetings and calibration sessions to ensure consistency in claim decisions and philosophy across the department.
Assist in preparing claim files and providing support for litigation or settlement conferences as required.

Required Skills & Competencies

Hard Skills (Technical)

Disability Claim Adjudication: Deep understanding of the process for evaluating and deciding on LTD claims.
Medical Terminology: Ability to comprehend and interpret complex medical records and physician reports.
Insurance Policy Interpretation: Skill in reading and applying the specific terms, conditions, and exclusions of group disability contracts.
ERISA & Regulatory Compliance: Strong working knowledge of ERISA guidelines and state-specific insurance regulations.
Vocational Assessment: Ability to analyze a claimant's education, work history, and transferable skills in relation to their functional capacity.
Benefit Calculation: Proficiency in calculating benefit amounts, including offsets for other income like SSDI and workers' compensation.
Claims Management Software: Experience using claims systems (e.g., ClaimVantage, V3) for documentation and file management.
Investigative Techniques: Skill in gathering and synthesizing information from various sources to make an informed decision.
Microsoft Office Suite: Proficiency in Word, Excel, and Outlook for communication, documentation, and data organization.
Dictation/Typing Skills: Ability to efficiently and accurately document extensive case notes and correspondence.

Soft Skills

Critical Thinking & Analytical Skills: Ability to evaluate complex, often conflicting information to reach a logical conclusion.
Empathy & Compassion: The capacity to interact with claimants in a supportive and understanding manner during a difficult time.
Exceptional Communication: Clear and concise written and verbal communication skills for interacting with a diverse range of stakeholders.
Negotiation & Conflict Resolution: The ability to manage disagreements and guide parties toward a mutually acceptable resolution.
Resilience & Composure: The capacity to handle difficult conversations, challenging situations, and claim denials professionally.
Time Management & Organization: Ability to prioritize tasks and manage a high-volume caseload effectively.
Attention to Detail: Meticulous approach to reviewing documents and maintaining accurate records.
Decision-Making: Confidence in making sound, well-documented, and defensible claim decisions.

Education & Experience

Educational Background

Minimum Education:

Associate's Degree or equivalent combination of education and relevant work experience.

Preferred Education:

Bachelor's Degree.

Relevant Fields of Study:

Business Administration, Healthcare Administration, Psychology
Nursing, Social Work, Vocational Rehabilitation, Kinesiology

Experience Requirements

Typical Experience Range:

2-5 years of direct experience in claims management, with a strong preference for experience in disability insurance (LTD or STD).

Preferred:

3+ years of experience managing a full caseload of LTD claims from inception to resolution. Professional designations such as a CLU (Chartered Life Underwriter) or an ALHC (Associate, Life and Health Claims) are highly regarded.