Claims Consultant

Responsibilities

• Provide absence case management and claim adjudications based on medical documentation and 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 (e.g., attending physician reports, medical records such as diagnostic tests, office notes, operative reports) to determine if the claimant is disabled as defined.
• Approve or deny FMLA claims according to insurance carrier and employer guidelines.
• Analyze, approve, and authorize assigned claims and determine benefits due pursuant to U.S. paid family law regulations.
• Review claims for "Not in Good Order" cases and secure missing documentation, including outreach to employees, physicians, or employers.
• 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, and review processes for accuracy and timeliness, including peer reviews.
• Provide ideas to management on continuous improvement and service level management.
• Perform other duties or participate in special projects as assigned.
• Identify escalated cases and work with the Team Leader to develop a plan to address key issues.

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.
• Excellent oral and written communication, including presentation skills.
• Strong analytical, decision-making, problem-solving, and people management skills.
• 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.

Qualifications

Associate degree.

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, Time Off, Sick Leave & Holidays.
• Legal & Financial Assistance: Legal Assistance, 401K Plan, Performance Bonus, College Fund, Student Loan Refinancing.

Pay

$48,000 - $55,000 per year.