The Claims Specialist manages absence cases and adjudicates disability, FMLA, and Paid Family Leave claims, ensuring accurate determination of benefits and timely payments. This role involves reviewing medical documentation, assessing eligibility, and collaborating with claimants, employers, and internal teams to deliver high-quality claims management.
Core Responsibilities
- Review and analyze claims, including eligibility and type (intermittent or continuous), and adjudicate benefits based on medical documentation and applicable regulations.
- Evaluate medical records (attending physician statements, diagnostic tests, office notes, operative reports, etc.) to determine disability status.
- Approve or deny FMLA claims according to employer guidelines and insurance carrier policies.
- Analyze and authorize assigned claims, determining benefits due pursuant to US paid family law and disability regulations.
- Identify claims not in good order and secure missing documentation through employee, physician, or employer outreach.
- Communicate clearly with claimants and clients via phone or written correspondence regarding claims processes and expectations.
- Review client deliverables, manage workload, and address first-level process escalations.
- Determine benefits due and make timely claims payments, approvals, and adjustments for Workers’ Compensation, State Short-Term Disability, and other disability offsets.
- Refer cases to Team Lead or Clinical Case Management as appropriate.
- Contribute to continuous improvement initiatives and service level enhancements.
- Participate in special projects or other duties as assigned.
Required Qualifications
- 1+ year of experience in Disability, FMLA, PFL, or insurance claims.
- Experience with FINEOS or similar claims management systems.
- Working knowledge of medical terminology and documents (APS, diagnostic tests, imaging reports).
- Knowledge of disability insurance claims, benefits administration, offsets, deductions, disability duration, and medical management practices.
- Strong oral and written communication skills, including the ability to present information clearly.
- Analytical, decision-making, problem-solving, and people management skills.
- Proficiency in MS Office (Excel, Word, PowerPoint) and general computer applications.
- Ability to thrive in a fast-paced, change-driven environment with a continuous learning mindset.
- Ability to identify escalated cases and collaborate with Team Lead to develop resolution plans.