Job Role : Claims Consultant
Location - Stone Mountain, GA (Remote)
Job Type : Full time Permanent
Salary Range: $48,000 - $55,000 per year
Job Description
Responsibilities:
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 the claim nuances, eligibility review, and type of
claims (intermittent or continuous)
Review and analyze medical information (i.e. 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
Analyzes, approves and authorizes assigned claims and determines benefits
due pursuant to US paid family law regulations.
Review claims for Not in good order cases, and work on securing missing
documentations including employee, physician, or employer outreach.
Communicates clearly with the claimants and clients to set expectations on
all aspects of claims process either by phone and/or written correspondence.
Reviews client critical deliverables, manages the overall workload, and
second-level process escalation.
Determines benefits due, makes timely claims payments/approvals and
adjustments for Workers Compensation, State Short Term Disability, and other
disability offsets.
Refers cases as appropriate to team lead and clinical case management
Responsible for managing the day-to-day workload and first-level process
escalation, and reviews processes for accuracy and timeliness where
applicable in case of peer reviews.
Provide ideas to management on continuous improvement and service level
management
Performs other duties or participates 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 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.