Claims Examiner - Leave Administration

You are: 

The Leave Administation Specialist for non-occupational and workers' compensation leaves, responsible for the proactive management of claims. This includes investgating initial claims, leave revalidation, facilitating return-to-work efforts, coordinate employee payroll and time tracking while on leave, and working with work site managers and/or human resources personnel for workplace accommodations according to restrictions implemented by employees' treating physicians.

You will: 

• Autonomously manage a daily task list within turnaround time expectations. 

• Investigate initial claims for approval under FMLA, PPL, STD (Preg/Maternity cases), and WC programs. 

• Support Nurse Case Manager in administering leaves under STD, LTD, FMLA, PPL, ADA, and WC Programs. 

• Interpret and correctly apply provisions of STD, LTD, FMLA, PPL, ADA, and WC Plans. 

• Determine if requested time-off is within acceptable guidelines. Request medical records from attending physician, completing non-complex outreach to physician offices, and consulting with nursing staff. 

• Support the Nurse Case Manager in the return-to-work process with the employee, human resources, supervisor, and third-party vendor until the employee is released to full duty. 

• Assist LTD claimant with Social Security filing(s) and Medicare approval. Update LTD claims for Social Security Award status. Audit and sign-off on coworkers’ LTD calculation sheets. 

• Coordinate pay on approved workers’ compensation cases with carrier and maintain claims in leave management system. Determine and establish accurate coding of unpaid (FMLA, ADA, WC) and paid (STD, PPL, LTD) leaves in HRIS system.  

• Ensure accurate application of state offsets, maintain offset calculators, and continuously monitor for any changes in offset amounts or the inclusion of new states. 

• Coordinate with 3rd party vendor for claim administration and lost time for Canadian leaves. 

• Assist the Nurse Case Manager in gathering all case materials to prepare an appeal before the Welfare Plan Committee. 

• As needed, work with HR legal department in drafting employee disability communications. 

• Complete annual LTD audit. 

• Perform Iron Mountain File archiving. 

• Provides training and support to Managers for any leaves related issue.  

• Delivers ongoing training to HR Support Line agents. 

• Troubleshoots and assists with leave management system; collaborate on resolution plans. 

• Create, audit, and distribute reports as needed. 

• Triage and address non-clinical Jira tickets. 

• Manage fax server documents/email inbox (Absence Management, Workers’ Compensation, Fitness Center). 

• Coordinate invoices/bill payments. 

• Manage and schedule all meetings. Draft and circulate meeting agendas and minutes. 

• Respond to all department subpoenas and requests for Absence Management documentation. 

• Complete all requests for disability pay information on state disability forms. 

• Complete special projects, and travel, as assigned. This includes assisting with projects within the Benefits department. 

Your Background 

As a Leave Administrative Specialist, you have: 

• 5+ years claims processing experiences within an insurance company or third-party administrator. 

• Experience in tightly managing claims and administering services on self-insured accounts. 

• Problem-solving ability. 

• Excellent written and verbal communication skills for both counseling and meeting presentations. 

• Excellent interpersonal skills and the ability to deal with all levels of management and employees on very sensitive and emotional issues. 

• Experience with good customer service standards. 

• Candidates need to demonstrate investigative and analytical skills, advanced written and verbal skills, a proven record in return-to-work programs, and understanding the social security disability insurance program. 

• Ability to work effectively within a team atmosphere. 

• Excellent computer skills. 

• Knowledge of benefit administration and/or similar administrative skills. 

• Complete understanding and application of all current plans and practices. 

• Ability to be completely objective and not easily swayed by the personal interest of unit administrators or individual employee claimants. 

• Familiarity with STD, FMLA, LTD, WC, ADA, PPL, state offsets, OSHA & safety rules & guidelines. 

Compensation:

The hourly wage range for this position is $32-$36 per hour. Actual compensation will be based on skills and experience as they relate to the job requirements and the location where you will be performing the job.

Location: 

Employees residing within 1hour driving distance of Shelton are required to travel to local office(s) as assigned, minimum four days per week. Subject to change based on business needs. 

Sponsorship: 

Must be legally authorized to work in the US. Employer will not sponsor position for employment visa status now or in the future (ex. H-1B).