Claims Specialist

Role Overview

The Claims Specialist will handle absence case management and claims adjudication using medical evidence and the relevant interpretation of Disability, FMLA, and Paid Family Leave rules. This includes deciding entitlement, calculating benefits, and ensuring payments and adjustments are completed on time.

Key Responsibilities

• Assess claim details, confirm eligibility, and distinguish between intermittent and continuous claim types.
• Examine medical records and supporting documents such as attending physician statements, diagnostic reports, office notes, operative notes, and similar files to establish disability status.
• Approve or deny FMLA claims in line with insurer requirements and employer guidelines.
• Review and authorize assigned claims, and determine benefit amounts under US paid family leave regulations.
• Identify incomplete or “not in good order” files and coordinate with employees, physicians, or employers to obtain missing documentation.
• Communicate with claimants and clients through phone and written communication to explain the process and set clear expectations.
• Monitor client deliverables, manage workload, and handle second-level escalations.
• Calculate benefits, process claim payments, approvals, and adjustments for Workers’ Compensation, State Short-Term Disability, and other disability offsets.
• Escalate cases to the team lead or clinical case management when needed.
• Handle day-to-day workload, support first-level escalations, and review peer work for accuracy and timeliness where required.
• Share improvement ideas with management to strengthen service levels and process quality.
• Complete additional duties and special projects as assigned.

Requirements

• At least 1 year of experience in Disability, FMLA, Paid Family Leave, or insurance claims.
• Prior exposure to FINEOS.
• Working knowledge of medical terminology and claim documents, including APS, diagnostic tests, and imaging reports.
• Understanding of disability insurance claims, benefits administration, offsets, deductions, disability duration, and medical management practices.
• Strong verbal and written communication skills, including presentation ability.
• Good analytical thinking, decision-making, problem-solving, and people management skills.
• Comfort with computer work, keyboarding, and software tools such as MS Office, including Excel, Word, and PowerPoint.
• Adaptability in a fast-moving work environment.
• Strong motivation to keep learning and improving.
• Ability to recognize escalated cases and partner with the Team Leader to address key issues.

Additional Information

This position is based in the United States and is a full-time onsite role. The source did not specify salary, perks, education requirements, number of openings, or start date.