Claims Examiner

Claims Examiner - Job Service Representative I (Long-Term Seasonal)

The Department of Family & Medical Leave (DFML) is seeking a customer-focused, detail-oriented professional to support the administration and integrity of the Commonwealth. The Job Service Representative I (JSR I) plays a critical role in assisting claimants and employers, reviewing claims escalated from the Contact Center, and ensuring accurate documentation and timely case resolution in accordance with applicable laws, regulations, and policies.

The mission of DFML is to implement and run the Commonwealths Paid Family & Medical Leave program, which provides income support to Massachusetts workers and their families during significant life events, while partnering with employers to ensure program integrity and compliance.

The Job Service Representative I, who reports to a Job Service Representative II, is responsible for supporting claims processing and customer service functions, including:

• Accepts and responds to incoming telephone calls from claimants
• Connects with applicants to guide them through the claim requirements and next steps
• Supports the program's live-chat functionality by responding to claimant inquiries
• Acknowledges the establishment of new claims and confirms receipt of required materials
• Reviews supporting documents for completeness and accuracy
• Documents all claimant information in the appropriate systems (CRM) following established protocols
• Maintains and monitors pending files to ensure timely progression
• Follows up with claimants or internal staff when additional information is needed
• Completes assigned tasks related to claim processing and case resolution
• Practices all policies and procedures related to PHI and HIPAA
• Ensures all interactions and documentation meet confidentiality, privacy, and program compliance standards
• Identify discrepancies or issues and escalate or remand to the appropriate internal department
• Prepare accurate case notations within claims management system which contain accurate, specific, and sufficient facts to address the standards of the law and allow accurate application of law, regulation, and policy
• Advise claimants and employers of appeal rights and procedures

Why should you join DFML? You want to work for a place that values your contributions and ideas, moves quickly in implementing solutions, and at the same time, allows you the flexibility to have a good balance between your personal and professional life. You will work with a dedicated team who are fueled by our mission of helping the people of the Commonwealth smoothly navigate our program during the big moments in their lives and will value you as both a coworker and as a person.

Qualifications:

• Basic to moderate knowledge of Microsoft Office products (Word, Excel, Powerpoint, Outlook)
• Ability to operate telecommunications equipment, personal computers and peripherals, fax and copier machines, optical scanners, etc.
• Knowledge of the methods of general report writing
• Ability to understand, explain and apply the laws, rules, policies, procedures, etc.
• Knowledge of principles and techniques of accurate, detailed fact-finding
• Ability to gather information in a telecommunications environment by questioning individuals and by examining records and documents
• Ability to assemble items of information according to established procedures and to record information received accurately and correctly
• Ability to analyze and determine the applicability of data, to draw conclusions and make appropriate recommendations
• Ability to analyze facts and arrive at sound conclusions
• Ability to perform basic mathematical
• Ability to meet deadlines in a timely and accurate manner
• Ability to establish rapport and deal effectively with persons from different ethnic and cultural backgrounds