Workflow Specialist Claims Processing

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 and determine benefits due for Workers Compensation, State Short Term Disability, and other disability offsets.
• Communicate with claimants and clients to set expectations on all aspects of the claims process.
• Manage the day-to-day workload and first-level process escalation.
• Refers cases as appropriate to team lead and clinical case management.
• Provides ideas to management on continuous improvement and service level management.

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 and work on escalated cases with Team Leader to develop a plan to address key issues.

Qualifications

• Diploma