Claims Consultant

Tata Consultancy Services; Port Saint Lucie (FL); On-site; USD 48,000 - 57,000; Full time

Benefits offered by this job

Discretionary Annual Incentive

Medical Coverage

Dental & Vision

Disability Insurance

Pet Insurance

Commuter Benefits

Certification & Training Reimbursement

Vacation & Holidays

401K Plan

Performance Bonus

College Fund

Student Loan Refinancing

Job summary

Tata Consultancy Services in Port Saint Lucie, FL is seeking an experienced claims professional to manage absence cases and adjudicate Disability/FMLA/PFL claims based on medical documentation. You will review claims, determine benefits due, communicate with claimants, and ensure timely payments while complying with regulations.

A diploma and 1+ year of relevant claims experience required; strong MS Office skills and knowledge of medical terminology are expected.

Qualifications

• 1+ year of Disability/FMLA/PFL claims or insurance claims experience.
• Experience working with FINEOS.
• Working knowledge of medical terminology and documents (APS, tests, records).
• Knowledge of disability insurance claims, benefits administration, offsets and deductions, duration and medical management.
• Excellent oral and written communication, including presentation skills.
• Strong analytical, decision making, problem solving, and people management skills.
• Proficiency in MS Office (Excel, Word, PPT).
• Willingness to embrace change in a fast paced environment.
• Desire to continuously learn and improve.
• Identify escalated cases and work with Team Leader to address key issues.

Responsibilities

• Provide absence case management and claim adjudications per disability/FMLA/PFL guidelines.
• Review claim nuances, eligibility, and type of claims.
• Determine benefits due and ensure timely payments and adjustments.
• Review medical information to determine disability status.
• Approve or deny FMLA claims per carrier and employer guidelines.
• Communicate with claimants and clients to set expectations.
• Manage workload and second-level process escalation.
• Provide ideas to management on continuous improvement and service level management.
• Perform other duties or participate in special projects as assigned.

Skills

Communication

Analytical skills

Decision making

Problem solving

People management

Adaptability

Education

Diploma

Tools

FINEOS

MS Office

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.
• 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.
• Review and analyze the claim nuances, eligibility review, and type of claims (intermittent or continuous)
• 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.
• Approval or denial on FMLA claims as per Insurance carrier, and employer’s guidelines
• Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to US paid family law regulations.
• Review claims for Not in good order cases, and work on securing missing documentations including employee, physician, or employer outreach.
• Communicates clearly with the claimants and clients to set expectations on all aspects of claims process either by phone and/or written correspondence.
• Reviews client critical deliverables, manages the overall workload, and second-level process escalation.
• Determines benefits due, makes timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets.
• Refers cases as appropriate to team lead and clinical case management
• 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.
• Provide ideas to management on continuous improvement and service level management
• Performs other duties or participates 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.

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 - $57,000 per year

Qualifications

• Diploma