Claim Specialist

Role Overview

The Claim Specialist will handle absence case management and adjudicate claims using medical evidence and the relevant interpretation of Disability, FMLA, and Paid Family Leave rules. The role includes assessing claim eligibility, deciding benefit entitlement, issuing timely payments and adjustments, and managing a variety of claim types in a U.S. claims environment.

Core Duties

• Evaluate claim details, eligibility, and whether a case is intermittent or continuous.
• Examine medical records and supporting documentation, such as physician statements, diagnostic test results, office notes, and operative reports, to determine disability status.
• Approve or deny FMLA claims according to carrier requirements and employer guidelines.
• Assess claims and authorize benefits in line with U.S. paid family leave regulations.
• Identify cases that are not complete, and follow up with employees, doctors, or employers to obtain missing information.
• Communicate expectations and claim updates clearly to claimants and clients through phone calls and written communication.
• Review client deliverables, handle workload priorities, and manage second-level process escalations.
• Calculate benefits, process payments and approvals on time, and make adjustments for workers’ compensation, state short-term disability, and other disability offsets.
• Escalate appropriate cases to the team lead and clinical case management.
• Manage daily work allocation, handle first-level escalations, and support peer review checks for accuracy and timeliness.
• Contribute ideas to management for service improvement and stronger SLA performance.
• Perform additional duties and support special projects as assigned.

Requirements

• At least 1 year of experience in Disability, FMLA, Paid Family Leave, or insurance claims handling.
• Prior experience using FINEOS.
• Working knowledge of medical terminology and claim-support documents, including APS, diagnostic reports, and imaging results.
• Understanding of disability insurance claims, benefits administration, offsets, deductions, disability duration, and medical management practices.
• Strong verbal and written communication skills, including the ability to present information clearly.
• Good analytical ability, judgment, problem-solving skills, and people coordination capability.
• Comfortable using computers and business software, with strong keyboarding ability and proficiency in MS Office tools such as Excel, Word, and PowerPoint.
• Open to change and able to work effectively in a fast-paced environment.
• Commitment to continuous learning and process improvement.
• Ability to recognize escalated cases and partner with the team lead to resolve key issues.

Additional Information

This position is based in the United States and is a full-time onsite role. No salary, stipend, openings count, start date, or application deadline were specified in the source information.