We are seeking a Claims Specialist with experience in disability and leave management to support end-to-end claims adjudication using FINEOS. The role involves reviewing medical documentation, determining eligibility, and managing claim decisions in compliance with FMLA, disability, and paid family leave regulations.
Roles and Responsibilities
- Manage absence cases and adjudicate disability/FMLA/Paid Family Leave claims using FINEOS
- Review medical documentation (APS, diagnostic tests, physician notes, imaging reports) to determine disability eligibility
- Approve or deny FMLA and disability claims in line with carrier and employer guidelines
- Determine benefits, offsets, and make timely claim payments and adjustments
- Handle intermittent and continuous claims including eligibility and case analysis
- Identify and resolve “not in good order” claims by obtaining missing documentation from employees, physicians, or employers
- Communicate claim decisions and updates clearly via phone and written correspondence
- Manage workload, ensure accuracy, and support first-level escalations
- Refer complex cases to team leads or clinical case management as needed
- Participate in peer reviews and ensure process accuracy and timeliness
- Support continuous improvement initiatives and process enhancements
Required Skills & Experience
- 1+ year of experience in Disability, FMLA, PFL, or insurance claims
- Hands-on experience with FINEOS claims platform
- Strong understanding of medical terminology and documentation (APS, diagnostic, imaging reports, etc.)
- Knowledge of disability insurance, benefits administration, offsets, and claim duration management
- Strong analytical, decision-making, and problem-solving skills
- Excellent written and verbal communication skills
- Proficiency in MS Office (Excel, Word, PowerPoint) and general computer applications
- Ability to work in a fast-paced, high-volume environment
- Strong attention to detail and willingness to learn and adapt
- Ability to identify escalations and collaborate with leadership on resolution planning