Claims Specialist

Responsibilities:

• To provide Absence case management and claim adjudications, based on medical documentation and the applicable Disability/FMLA/Paid Family Leave interpretation , including determining benefits due and making timely payments and adjustments.
• Review and analyze the claim nuances, eligibility review, and type of claims (intermittent or continuous)
• Review and analyze medical information (i.e. attending physician reports, medical records such as diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined.
• Approval or denial on FMLA claims as per Insurance carrier, and employer’s guidelines
• Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to US paid family law regulations.
• Review claims for Not in good order cases, and work on securing missing documentations including employee, physician, or employer outreach.
• Communicates clearly with the claimants and clients to set expectations on all aspects of claims process either by phone and/or written correspondence.
• Reviews client critical deliverables, manages the overall workload, and second-level process escalation.
• Determines benefits due, makes timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets.
• Refers cases as appropriate to team lead and clinical case management
• Responsible for managing the day-to-day workload and first-level process escalation, and reviews processes for accuracy and timeliness where applicable in case of peer reviews.
• Provide ideas to management on continuous improvement and service level management
• Performs other duties or participates in special projects as assigned

Requirements:

• 1+ year of Disability/FMLA/PFL claims or insurance claims experience
• Experience working with FINEOS
• Working knowledge of medical terminology and documents, including APS, Diagnostic Tests, Imaging Tests reports
• Knowledge of disability insurance claims, benefits administration, offsets and deductions, disability duration and medical management practices mandatory
• Excellent oral and written communication, including presentation skills
• Strong Analytical, decision making, problem solving, and people management skills
• Computer experience with keyboarding skills and proficiency in using software applications and packages including MS Office (Excel, Word, PPT)
• Willingness to embrace change in a fast paced work environment
• A strong desire to continuously learn and improve
• Identify escalated cases and work with Team Leader to develop a plan to address key issues.