Position: Claims Specialist
Location: Remote
Duration: FTE/ Direct Hire
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.
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