Absence Case Specialists

The Absence Case Specialists (ACS) 

SUMMARY: 

The Absence Case Specialists (ACS) works with employers, employees and health care providers to administer an integrated Family and Medical Leave Act (FMLA) rights and responsibilities and Short Term Disability claim.  Provides advice and counsel regarding leave administration and effectively coordinates all cases/claims in compliance with the FMLA and all related employment laws.  Responsible for the professional management of both routine and complex claims for Group Short Term Disability while working both independently and in a team to ensure superior service to policyholders and claimants.  Reviews claims and makes final determination for admittance or denial.  Approves payment of claims and Company liability within established limits. 

 ESSENTIAL DUTIES AND RESPONSIBILITIES:

The ACS possesses excellent Disability and Absence Management knowledge with demonstrated expertise in Federal/State FMLA, short-term disability, statutory disability plans, and ADA.  The ACS works within a team environment among a peer group and business partners with related subject matter expertise to service client needs related to absence, disability and accommodations. The responsibilities include:

·      Interprets and administers leave programs and policies in accordance with the applicable federal and state employment laws (FMLA, ADA, USERRA, Pregnancy Discrimination Act, etc.).

·      Facilitation and engagement in interactive dialogue with employees, medical professionals, supervisors, and HR business partners to assist employees.  

·      Documentation of the request for absence including detailed points of contact and actions taken to coordinate the accommodation request.

·      Reviews claim payments within established limits and/or reviews recommendations made by medical resources to determine proper disposition of claims.

·      Sets claim action plan to ensure that determinations are adjudicated in a timely, accurate, and efficient manner.

·      Interprets contracts and ensures consistent, fair claims practices and adherence to appropriate laws, regulations, and procedures.

·      Obtains backup documentation, as necessary, to substantiate claim or to provide service by communicating via telephone with agents, employers (policyholders), claimants, hospitals, physicians, attorneys, and other resources.

·      May handle other related duties such as providing technical assistance to other Claims staff or assisting in special projects or assignments as a result of business needs.

·      Protect and maintain personal health information with a high level of confidentiality abiding by Sun Life procedures and by HIPPA rules and regulations.

Critical Skills / Must-Haves:

1.       1-2 years of customer / financial services experience.

2.       Effective ability to use legal resources and demonstrate a proven ability to comprehend and interpret legal and medical terminology in order to make final decisions to approve or further investigate claims

3.       Demonstration of strong mathematical skills for calculations and adjustment of claim payments.

4.       Strong computer skills, proficient in PC environment and MS Word, Excel, and email systems.

Required Soft Skills:

·         Communicating effectively and professionally with a wide variety of both internal and external business partners, peers and resources.

·         Attention to detail with documentation, reporting and communication.

·         Facilitation skills in a variety of circumstances and with a wide variety of input.  Ability to influence and teach. 

·         Self-directed with an ability to work independently and make independent judgments and decisions.

·         Strong organizational skills, including the ability to prioritize work and multi-task.

·         Strong research, analytical, critical thinking, problem solving skills and decision-making skills.

·         Ability and desire to work in a fast-paced, service-oriented environment.

·         Excellent verbal communication skills, with the ability to be both pleasant and professional.

·         Strong written communication skills.

·         Strong interpersonal and customer service skills.

·         Ability to initiate and prioritize regular work duties and projects.

·         Detail oriented, organized, the ability to multi-task, and strong time management skills.

·         Ability to work professionally and effectively with co-workers, clients, claimants, vendors and others with whom Client does business.

PHYSICAL DEMANDS: 

While performing the duties of this job the employee is required to stand, move from one room to another, and frequently sit.  The employee must talk or listen, and use hands to finger, handle or touch in the context of navigating a computer keyboard and phone system.

The employee must be able to understand the spoken word, written word, both hard-copy and on-line and must be able to respond in kind.

The employee must be able to operate standard business equipment including a computer and a variety of software applications.

Nice-to-Haves:

1.       Is healthcare, insurance, TPA, employer leave administration, or carrier experience preferred

2.       Claims background, medical terminology

Education: Bachelor's degree preferred but not required.