Claims Consultant

Tata Consultancy Services; Davison (MI); On-site; USD 48,000 - 55,000; Full time

Benefits offered by this job

Medical Coverage

401K Plan

Performance Bonus

Time Off

Certification & Training Reimbursement

Job summary

Tata Consultancy Services seeks an experienced disability claim professional to manage absence case management, FMLA/PFL adjudications, and benefits determination based on medical documentation and regulatory guidelines.

You will review medical information, determine eligibility, authorize payments, and communicate decisions to claimants and clients. The role requires strong analytical skills, proficiency with MS Office, and the ability to adapt in a fast-paced environment.

Qualifications

• 1+ year of Disability/FMLA/PFL claims or insurance claims experience.
• Experience with FINEOS.
• Knowledge of disability insurance claims, benefits administration, offsets and deductions, disability duration and medical management practices.
• Excellent oral and written communication, including presentation skills.
• Strong analytical, decision making, problem solving, and people management skills.
• Computer experience with keyboarding skills and proficiency in MS Office (Excel, Word, PPT).
• Willingness to embrace change in a fast paced work environment.
• A strong desire to continuously learn and improve.
• Identify escalated cases and work with Team Leader to develop a plan to address key issues.

Responsibilities

• Review and analyze claim nuances, eligibility review, and type of claims (intermittent or continuous).
• Review and analyze medical information (e.g., attending physician reports, medical records such as diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined.
• Approval or denial on FMLA claims as per Insurance carrier and employer’s guidelines.
• Analyze, approve and authorize assigned claims and determine benefits due pursuant to US paid family law regulations.
• Review claims for Not in good order cases and work on securing missing documentation including employee, physician, or employer outreach.
• Communicate clearly with the claimants and clients to set expectations on all aspects of the claims process either by phone and/or written correspondence.
• Review client critical deliverables, manage the overall workload, and second-level process escalation.
• Determine benefits due, make timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets.
• Refer cases as appropriate to team lead and clinical case management.
• Manage day-to-day workload and first-level process escalation, and review processes for accuracy and timeliness where applicable in case of peer reviews.
• Provide ideas to management on continuous improvement and service level management.
• Perform other duties or participate in special projects as assigned.

Skills

Disability/FMLA/PFL claims experience

FINEOS

Medical terminology

Disability insurance knowledge

Oral and written communication

Analytical thinking

MS Office proficiency

Adaptability

Continuous learning

Escalation management

Education

Associateship

Tools

FINEOS

MS Office (Excel/Word/PPT)

Job description

Job Description

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.

Responsibilities

• Review and analyze claim nuances, eligibility review, and type of claims (intermittent or continuous).
• Review and analyze medical information (e.g., attending physician reports, medical records such as diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined.
• Approval or denial on FMLA claims as per Insurance carrier and employer’s guidelines.
• Analyze, approve and authorize assigned claims and determine benefits due pursuant to US paid family law regulations.
• Review claims for "Not in good order" cases and work on securing missing documentation including employee, physician, or employer outreach.
• Communicate clearly with the claimants and clients to set expectations on all aspects of the claims process either by phone and/or written correspondence.
• Review client critical deliverables, manage the overall workload, and second-level process escalation.
• Determine benefits due, make timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets.
• Refer cases as appropriate to team lead and clinical case management.
• Manage day-to-day workload and first-level process escalation, and review processes for accuracy and timeliness where applicable in case of peer reviews.
• Provide ideas to management on continuous improvement and service level management.
• Perform other duties or participate in special projects as assigned.

Requirements

• 1+ year of Disability/FMLA/PFL claims or insurance claims experience.
• Experience working with FINEOS.
• Working knowledge of medical terminology and documents, including APS, Diagnostic Tests, Imaging Tests reports.
• Knowledge of disability insurance claims, benefits administration, offsets and deductions, disability duration and medical management practices (mandatory).
• Excellent oral and written communication, including presentation skills.
• Strong analytical, decision making, problem solving, and people management skills.
• Computer experience with keyboarding skills and proficiency in using software applications and packages including MS Office (Excel, Word, PPT).
• Willingness to embrace change in a fast paced work environment.
• A strong desire to continuously learn and improve.
• Identify escalated cases and work with Team Leader to develop a plan to address key issues.

Qualifications

Associateship.

TCS Employee Benefits Summary

• Discretionary Annual Incentive.
• Comprehensive Medical Coverage: Medical & Health, Dental & Vision, Disability Planning & Insurance, Pet Insurance Plans.
• Family Support: Maternal & Parental Leaves.
• Insurance Options: Auto & Home Insurance, Identity Theft Protection.
• Convenience & Professional Growth: Commuter Benefits & Certification & Training Reimbursement.
• Time Off: Vacation, Time Off, Sick Leave & Holidays.
• Legal & Financial Assistance: Legal Assistance, 401K Plan, Performance Bonus, College Fund, Student Loan Refinancing.

Salary Range: $48,000 - $55,000 per year.