Specialist

Job Description

asic Function Handle and administer Family Medical Leave Act standalone (as well as other leave) claims and adhere to federal and state regulatory and/or company plan requirements and established FMLA workflow procedures Complete eligibility decisions and review for entitlement, gather pertinent data when necessary, from employee, physicians office or employer through outgoing calls, email, fax or other supporting systems. Promptly review new FMLA and other leave claims within regulatory timelines, evaluate against appropriate leave plans and make initial claim decision. Perform leave administration tasks as required, including recertification of health condition, intermittent claim tracking, RTW confirmation, return phone calls, etc. Update systems to accurately reflect leave status and ensure appropriate diary documentation exists Business recommended TAT to complete the activity is up to 5 business days to maintain compliance measures The position is expected to do absence management and adjudication on Federal, State and company leaves. Interact with claim specialist, claim support specialist, QA, Claims Unit Leader (stateside supervisors), employees, employers/customer and physician s office Essential Functions: Analyze, validate and process transactions as per Desktop procedures (L3 L4) Analyze and research all discrepancies Research Investigate and resolve outstanding items Determine eligibility, entitlement and applicable plan provisions while meeting timeliness goals Clear and accurate written and verbal communication (Mix of scripted/unscripted) with employee, employer stateside resources by email and outgoing calls Establish action plans for each file to bring claims to resolution Utilize internal and external specialty resources to maximize impact on each claim file Use PC programs to increase productivity and performance Ensure that the assigned targets are met in accordance with SLA, Performance Guarantee and Internal standards Ensure that the quality of transaction is in compliance with predefined parameters as defined by Process Excellence Work as a team member to meet office goals to obtain disability s vision while demonstrating core values and meeting key measures Ensure adherence to established attendance schedules Close visual activity - viewing a computer terminal and extensive reading Any other essential function that may occur from time to time as directed by the Supervisor. Primary Internal Interactions UM for the purpose of reporting performance, escalation handling, clarifying concerns, and seeking feedback and support Manager for the purpose of settling issues left unresolved by the AM and monthly evaluation of performance Subject Matter Expert for the purpose of work thread related issues and escalated transactions QCA for the purpose of feedback and internal Performance Guarantee quality audit team Trainers for the purpose of Pre-process and Process DCA training Disability Customer Advocates for escalation resolution Primary External Interactions End customer to be contacted through emails/calls for information gathering/decision update Claims specialist other Stateside Teams on emails/calls SME / Trainers at the client end for training