TL - Claims Specialist

Talent Advisors; Dadri; On-site; INR 600,000 - 1,000,000; Full time

Job summary

Talent Advisors in India is seeking a Claims Specialist to manage end-to-end STD claims, acting as primary contact for claimants and coordinating with employers and medical providers. You will review eligibility, make timely decisions, communicate updates, and ensure accurate data entry while maintaining HIPAA confidentiality. Candidates with 5–9 years in transactional insurance claims and experience with statutory leave types will be preferred.

Qualifications

• Minimum 5-9 years in transactional insurance claims processes.
• Experience with STD/FMLA claims knowledge preferred.

Responsibilities

• Create and execute individual claim action plans.
• Serve as point of contact for claimants with timely communication.
• Update systems and diary documentation reflecting claim status.
• Make initial and subsequent claim decisions within policy guidelines.
• Ensure timely and accurate case management across leave types.
• Maintain confidentiality and HIPAA compliance.

Skills

Communication skills

Customer service

Claims management

HIPAA compliance

Data integrity

Financial decision making

Tools

Claims System

Job description

As a Claims Specialist, the essential role would be in managing overall STD block of claims, acting as point of contact for claimant fulfilling this commitment by providing professional communication and claims decision making (including financials) to our claims team and customers. Help ensure timely and accurate handling & ownership of claims management including Statutory plans, Federal, Company, State and other Leave types.

Basic Function

• Administer STD claims
• Complete eligibility decisions, gather pertinent data, when necessary, from employee, employer, physicians office or employer through outgoing calls, email, fax or other supporting systems.
• Promptly review new STD Claims and make initial & subsequent claim decisions.
• Perform discussion on health condition, RTW confirmation, return phone calls, etc.
• Update systems to accurately reflect claim status and ensure appropriate diary documentation exists
• Business recommended TAT to complete the activity within the required number of business days, specific to task types, to maintain compliance measures
• The position is expected to do end to end management including Statutory plans, Federal, Company, State and other Leave types.
• Interact with claim specialists, claim support specialist, QA, Claims Unit Leader (stateside supervisors), employees, employers/customer and physicians office

Essential Functions

• Creates and executes individual claim action plans, serves as point of contact for claimant and provides a high-level of service to the claimant, including timely return of phone calls, clear communication, and decision making.
• Proactively communicates/updates to partners that may be working with the claimant when key events are being considered or have occurred (Closure, RTW, etc.)
• Meet and Exceed Operational Efficiency goals, Demonstrate Service Delivery and Customer Satisfaction goals, including prioritizing actions, appropriately utilizing resources timely, maintaining data integrity through accurate benefit decision and payment
• Accountable for accurate financial decisions on block of claims with financial base benefit amounts up to $8000 per week per claim decisions made in accordance with Customer provisions
• Utilize internal and external specialty resources to maximize impact on each claim file.
• Ensure that the assigned targets are met in accordance with SLA, compliance and internal standards,
• Maintain accurate and up-to-date information in the claims database.
• Use the Claims System for end-to-end case management, including inquiries and correspondence.
• Maintain confidentiality and comply with HIPAA regulations in managing sensitive information.

Experience

Minimum 5-9 years in a transactional, blended (With voice) process of insurance (especially STD and Family Medical Leave Act claims knowledge) or related industry with relevant experience of working in a business environment (preferred in insurance or disability domain)

Resources should be voice-skilled with unscripted calls to Claimant and all other related parties for end-to-end case management.