Qureos Mentor

Holistic Partners, Inc

<div>
 
 
 Job Description
 
 
 
 
 Role: Claims Specialist
 
 
 
 
 Location: Milton, PA Remote
 
 
 
 
 Duration: Full Time
 
 
 
 
 
 
 
 Responsibilities:
 
 
 <ul>
 <li>
 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.
 </li>
 <li>
 Review and analyze the claim nuances, eligibility review, and type of claims (intermittent or continuous)
 </li>
 <li>
 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.
 </li>
 <li>
 Approval or denial on FMLA claims as per Insurance carrier, and employer&rsquo;s guidelines
 </li>
 <li>
 Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to US paid family law regulations.
 </li>
 <li>
 Review claims for Not in good order cases, and work on securing missing documentations including employee, physician, or employer outreach.
 </li>
 <li>
 Communicates clearly with the claimants and clients to set expectations on all aspects of claims process either by phone and/or written correspondence.
 </li>
 <li>
 Reviews client critical deliverables, manages the overall workload, and second-level process escalation.
 </li>
 <li>
 Determines benefits due, makes timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets.
 </li>
 <li>
 Refers cases as appropriate to team lead and clinical case management
 </li>
 <li>
 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.
 </li>
 <li>
 Provide ideas to management on continuous improvement and service level management
 </li>
 <li>
 Performs other duties or participates in special projects as assigned
 </li>
 </ul>
 
 
 
 
 
 Requirements:
 
 
 <ul>
 <li>
 1+ year of Disability/FMLA/PFL claims or insurance claims experience
 </li>
 <li>
 Experience working with FINEOS
 </li>
 <li>
 Working knowledge of medical terminology and documents, including APS, Diagnostic Tests, Imaging Tests reports
 </li>
 <li>
 Knowledge of disability insurance claims, benefits administration, offsets and deductions, disability duration and medical management practices mandatory
 </li>
 <li>
 Excellent oral and written communication, including presentation skills
 </li>
 <li>
 Strong Analytical, decision making, problem solving, and people management skills
 </li>
 <li>
 Computer experience with keyboarding skills and proficiency in using software applications and packages including MS Office (Excel, Word, PPT)
 </li>
 <li>
 Willingness to embrace change in a fast paced work environment
 </li>
 <li>
 A strong desire to continuously learn and improve
 </li>
 <li>
 Identify escalated cases and work with Team Leader to develop a plan to address key issues.
 </li>
 </ul>
</div>

Claims Specialist

Join Holistic Partners, Inc and explore 1   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Holistic Partners, Inc

About Company

Claims Specialist