Specialist

Basic Function:
 Handle and administer Family & Medical Leave Act standalone (as well as other leave) claims and adhere to federal and
state regulatory and/or company plan requirements and established FMLA workflow procedures
 Complete eligibility decisions and review for entitlement, gather pertinent data when necessary, from employee,
physicians office or employer through outgoing calls, email, fax or other supporting systems.
 Promptly review new FMLA and other leave claims within regulatory timelines, evaluate against appropriate leave plans
and make initial claim decision.
 Perform leave administration tasks as required, including recertification of health condition, intermittent claim tracking, RTW
confirmation, return phone calls, etc.
 Update systems to accurately reflect leave status and ensure appropriate diary documentation exists
 Business recommended TAT to complete the activity is up to 5 business days to maintain compliance measures
 The position is expected to do absence management and adjudication on Federal, State and company leaves.
 Interact with claim specialist, claim support specialist, QA, Claims Unit Leader (stateside supervisors), employees,
employers/customer and physician’s office

Essential Functions:
 Analyze, validate and process transactions as per Desktop procedures (L3 & L4)
 Analyze and research all discrepancies
 Research & Investigate and resolve outstanding items
 Determine eligibility, entitlement and applicable plan provisions while meeting timeliness goals
 Clear and accurate written and verbal communication (Mix of scripted/unscripted) with employee, employer & stateside
resources by email and outgoing calls
 Establish action plans for each file to bring claims to resolution
 Utilize internal and external specialty resources to maximize impact on each claim file
 Use PC programs to increase productivity and performance
 Ensure that the assigned targets are met in accordance with SLA, Performance Guarantee and Internal standards
 Ensure that the quality of transaction is in compliance with predefined parameters as defined by Process Excellence
 Work as a team member to meet office goals to obtain disability’s vision while demonstrating core values and
meeting key measures
 Ensure adherence to established attendance schedules
 Close visual activity - viewing a computer terminal and extensive reading
Any other essential function that may occur from time to time as directed by the Supervisor.

Skills:

Technical Skills:

 Good computer navigation skills
 Good keyboarding speed
 Good knowledge of complete MS Office suite

Process Specific Skills:

 Knowledge about the Insurance industry in US
 Knowledge about US Culture
 Knowledge of Insurance principles

Soft skills (Mandatory / Desired):

 Communication skills – should be able to read, interpret
business documents. Good verbal/written communication
 Proficiency in English – Spoken and Written
 Analytical and interpersonal skills
 Escalate issues if required
 Data gathering ability/ Eye for detail
 Team work/ Managing Self / Adaptability
 Ability to work successfully in production driven
environment
 Adaptability to change
 Ability to work on routine/standardized transactions
Desired:
 Self disciplined and result oriented
 Ability to multi task
 Ability to work effectively as part of a team
 Knowledge of Medical Terminology (preferred but not
compulsory)
Preferred:
 Claims, specifically disability, preferred
 Working knowledge of FMLA/Disability/Leave procedures
preferred
 Knowledge of system applications preferred

Education Requirements
Graduate with at least 15 years of education.

Work Experience Requirements
Minimum 3-4 years of experience in a transactional, blended process of insurance or related industry with
relevant experience of working in a business environment (preferred but not compulsory)