Claims Consultant

Responsibilities

• Provide Absence case management and claim adjudications, based on medical documentation and the applicable Disability/FMLA/PFL interpretation.
• Determine benefits due and make timely payments and adjustments.
• Analyze and approve FMLA claims as per Insurance carrier and employer guidelines.
• Analyze, approve, and authorize assigned claims and determine benefits due according to US paid family law regulations.
• Review and secure missing documentations for Not in good order cases, including employee, physician, or employer outreach.
• Communicate with claimants and clients regarding all aspects of the claims process, setting clear expectations through phone and/or written correspondence.
• Manage the overall workload and 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.
• Refers cases as appropriate to team lead and clinical case management.
• Manage day-to-day workload and first-level process escalation, reviewing processes for accuracy and timeliness where applicable in case of 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, Imaging Tests reports.
• Knowledge of disability insurance claims, benefits administration, offsets and deductions, disability duration and medical management practices.
• 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.

Qualifications

• Associateship.