Workflow Specialist Claims Processing

Tata Consultancy Services; Cypress (TX); On-site; USD 50,000 - 53,000; Full time

Benefits offered by this job

Discretionary annual incentive

Comprehensive medical coverage

Maternal & parental leaves

Auto & home insurance

Commuter benefits

Certification & training reimbursement

Vacation & holidays

401K plan

Job summary

Tata Consultancy Services is seeking a claims professional to manage absence cases, adjudicate FMLA/PFL claims, and determine benefits based on medical documentation and applicable regulations. The role requires reviewing medical records and communicating decisions to claimants and clients.

Ideal candidates will have 1+ year of disability claims experience, familiarity with FINEOS, and strong analytical and communication skills within a fast-paced environment.

Qualifications

• Disability/FMLA/PFL claims experience is required.
• Knowledge of disability insurance claims and benefits administration.
• Familiarity with medical terminology and documentation.
• Strong communication and analytical abilities are essential.
• Proven problem-solving skills and teamwork orientation.

Responsibilities

• Provide absence case management and claim adjudications based on medical documentation.
• Review claim nuances, eligibility, and type of claims (intermittent/continuous).
• Analyze medical information to determine disability status and benefits.
• Approve or deny FMLA claims per carrier and employer guidelines.
• Communicate with claimants and clients to set expectations throughout the process.

Skills

Disability/FMLA/PFL claims experience

Analytical thinking

Excellent communication

Problem-solving

Team leadership/people-management

Adaptability

MS Office proficiency

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.

Responsibilities

• 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 (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.
• Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to U.S. paid family law regulations.
• Review claims for Not in Good Order cases, and work on securing missing documentation including employee, physician, or employer outreach.
• Communicates clearly with the claimants and clients to set expectations on all aspects of the 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.
• Provides 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, and imaging 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, PowerPoint).
• 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.
• Diploma.

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: $50,000 - $53,000 per year