Claims Consultant

Tata Consultancy Services; Winter Park (FL); On-site; USD 48,000 - 55,000; Full time

Benefits offered by this job

Annual incentive

Medical coverage

Family leaves

Insurance options

Commuter benefits

Training reimbursement

Vacation & time off

Legal & financial assistance

Job summary

Tata Consultancy Services in the United States is seeking an Absence/Disability claims specialist to manage FMLA/Paid Family Leave, review medical documentation, determine benefits due and ensure timely payments. Collaboration with claimants and clients is essential, with adherence to regulatory guidelines.

You will analyze claims, approve/deny FMLA cases, and escalate issues as needed while maintaining service levels and process improvements.

Qualifications

• 1+ year of Disability/FMLA/PFL claims or insurance claims experience.
• Experience working with FINEOS.
• Working knowledge of medical terminology and documents (APS, diagnostic tests, imaging reports).
• Knowledge of disability insurance claims, benefits administration, offsets and deductions.
• Excellent oral and written communication, including presentation skills.
• Strong analytical, decision making, problem solving, and people management skills.
• MS Office proficiency (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 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.
• Review claims for Not in good order and secure missing documentation.
• Communicate with claimants and clients to set expectations on the claims process.
• Review client deliverables, manage workload, and escalate as needed.
• Determine benefits due and make timely payments/adjustments for various disabilities.
• Refer cases to team lead and clinical case management as appropriate.
• Manage day-to-day workload and first-level process escalation.
• Provide ideas for continuous improvement and SLA management.
• Perform other duties or participate in special projects.

Skills

Disability claims

FMLA/PFL

Medical terminology

Disability insurance

Communication skills

Analytical thinking

Case escalation

Change readiness

Continuous learning

Education

Associateship

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.

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.