Claims Adjudicator - State Program Administrator Intermediate

About the role

The Claims Adjudicator performs front-line, specialized program support work for the Paid Leave division. Under general supervision, the Claims Adjudicator provides effective and efficient review and processing of claims and direct support to applicants by offering guidance and maintaining clear communication throughout the claims process. The Claims Adjudicator is responsible for carrying out program activities to ensure eligibility requirements are met, documentation is provided as required and to ensure compliance with program guidelines.

Responsibilities

• Provide effective and efficient review and processing of claims for the Paid Leave program: Consistently meet accuracy and quality standards, service level agreements and ensure that compliance with program guidelines is always maintained.
• Case Management: Monitor, document, and follow-up on assigned claims. Partner with internal teams as needed to ensure program guidelines and Service Level Agreements (SLAs) are met.
• Cross-functional Program Support: During program implementation, the Adjudicator may need to participate in supporting program needs. This could involve but is not limited to user acceptance testing (UAT), assisting the Contact Center by taking phone calls during periods of high call volume, and other duties as assigned.

Requirements

• One (1) year* of experience in claims, appeals, case management operations, or contact center support for an eligibility or claims-based program.
• Associate's degree in Business Administration, Public Administration, Community Development, Economics, Human Resources, or other closely related field as determined by the agency may substitute six (6) months of experience; bachelor's degree substitutes for one (1) year of experience; master's degree substitutes for eighteen (18) months of experience.

Qualifications

• Knowledge of standard operating procedures for reviewing and processing claims.
• Knowledge of data protection laws (e.g. HIPAA) and the handling of sensitive applicant information.
• Knowledge of state and federal regulations regarding family and medical leave.

Skills

• Experience entering, reviewing and updating information in digital systems.
• Ability to research, interpret, and clearly communicate program requirements and policies.
• Ability to identify issues in applications and find solutions, i.e. requesting additional documentation or clarification.
• Ability to manage a high workload, prioritize tasks and meet deadlines and quality expectations.
• Ability to adapt effectively to new technologies, procedures, or policy changes.