Claims Specialist

Only USC and GC Job Description – Claim Specialist with FineOS Responsibilities Provide absent 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, etc.) to determine if the claimant is disabled as defined. Approve or deny FMLA claims as per insurance carrier and employer’s 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 through employee, physician, or employer outreach. 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 the 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 the 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. 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 test 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. #J-18808-Ljbffr