Claims Consultant

Job Description

To 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 review, 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, etc.) to determine if the claimant is disabled as defined.
• Approval or denial on FMLA claims as per Insurance carrier and employer’s 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 work on securing missing documentation including employee, physician, or employer outreach.
• Communicate clearly with the claimants and clients to set expectations on all aspects of the claims process either by phone and/or written correspondence.
• Review client critical deliverables, 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.
• 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 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.

• 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 (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 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.

Associateship.

• 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.

Salary Range: $48,000 - $55,000 per year.