Claims Specialist - Operations

Talent Advisors; Dadri; On-site; INR 500,000 - 800,000; Full time

Job summary

Talent Advisors is looking for an individual to manage and administer Family & Medical Leave Act (FMLA) claims in Dadri, Uttar Pradesh. The role includes responsibilities like analyzing claims, determining eligibility, and ensuring compliance with established regulatory timelines.

The ideal candidate should possess strong analytical skills, effective communication abilities, and a keen understanding of leave administration. This position plays a critical part in maintaining compliance measures while working closely with employees, employers, and other stakeholders.

Qualifications

• Experience with Family & Medical Leave Act (FMLA) processes.
• Strong analytical and problem-solving skills.
• Proficient in communication (both written and verbal).

Responsibilities

• Administer FMLA claims according to compliance requirements.
• Make eligibility decisions and manage leave administration tasks.
• Interact with various stakeholders to resolve claims.

Job description

Basic Function

• Handle and administer Family & Medical Leave Act (FMLA) standalone claims, as well as other leave claims, and adhere to federal, state regulatory, and company plan requirements and established FMLA workflow procedures.
• Complete eligibility decisions and review for entitlement, gather pertinent data when necessary from employee, physician’s 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 decisions.
• Perform leave administration tasks as required, including recertification of health condition, intermittent claim tracking, RTW confirmation, and return phone calls.
• Update systems to accurately reflect leave status and ensure appropriate diary documentation exists.
• Business recommended turnaround time is up to 5 business days to maintain compliance measures.
• 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/customers, and physicians’ 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.
• Provide clear and accurate written and verbal communication (mix of scripted and unscripted) with employees, employers, and stateside resources via 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 assigned targets are met in accordance with SLA, Performance Guarantee, and internal standards.
• Ensure the quality of transactions complies with predefined parameters as defined by Process Excellence.
• Work as a team member to meet office goals and obtain disability vision while demonstrating core values.
• Ensure adherence to established attendance schedules.
• Close visual activity by viewing a computer terminal and extensive reading.