Overview
Claims Specialist Jobs in United States at Holistic Partners, Inc
Title: Claims Specialist
Company: Holistic Partners, Inc
Location: United States
Position: Claims Specialist
Location: Remote
Duration: Full Time
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.
