Claims Consultant

Responsibilities

• 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 claim nuances, eligibility, and type of claims (intermittent or continuous).
• Review and analyze medical information (attending physician reports, medical records such as diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined.
• Approve or deny FMLA claims per insurance carrier and employer guidelines.
• Analyze, approve, and authorize assigned claims and determine benefits due pursuant to US paid family law regulations.
• Review claims for Not in Good Order cases and secure missing documentation through employee, physician, or employer outreach.
• Communicate clearly with claimants and clients to set expectations on all aspects of the claims process via phone and/or written correspondence.
• Review client critical deliverables, manage overall workload, and handle second‑level process escalation.
• Determine benefits due, make timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets.
• Refer cases as appropriate to team lead and clinical case management.
• Manage day‑to‑day workload and first‑level process escalation; review processes for accuracy and timeliness in peer reviews.
• Provide ideas to management on continuous improvement and service level management.
• Perform other duties or participate 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, and imaging test 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 MS Office (Excel, Word, PowerPoint).
• Willingness to embrace change in a fast‑paced work environment.
• Strong desire to continuously learn and improve.
• Ability to identify escalated cases and work with a Team Leader to develop a plan to address key issues.

Qualifications

Diploma

Benefits

• Discretionary Annual Incentive.
• Comprehensive Medical Coverage: medical & health, dental & vision, disability planning & insurance, pet insurance plans.
• Family Support: maternal & parental leaves.
• Insurance Options: auto & home insurance, identity theft protection.
• Convenience & Professional Growth: commuter benefits, certification & training reimbursement.
• Time Off: vacation, sick leave, holidays.
• Legal & Financial Assistance: legal assistance, 401(k) plan, performance bonus, college fund, student loan refinancing.

Pay

Salary Range: $48,000 – $57,000 per year.