Claims Examiner - Job Service Rep I

Commonwealth of Massachusetts•Boston, MA

About The Position

Claims Examiner/Job Service Representative I| Department of Family & Medical Leave The Program Integrity Claims Examiner/Job Service Representative I is responsible for supporting processes within the Department of Family Medical Leave (DFML). The Claims Examiner/Job Service Representative I will review claims escalated by the Contact Center and internal DFML staff in accordance with applicable laws, regulations, and policies; Incumbent will perform related duties as required. Who we are: DFML’s mission is to implement and run the Commonwealth’s Paid Family & Medical Leave program that provides income support to Massachusetts workers and their families during significant life events while serving as a partner to employers to deliver program integrity. What you’d do: Claims Examiner/Job Service Representative I, who reports to the Senior Manager of Benefit Operations & Program Integrity is based in Boston, MA, and is responsible for the following: Facilitate the program integrity of the DFML by ensuring claims filed with the Department of Family and Medical Leave (DFML) are consistent with applicable laws, regulations, and policies (M.G.L. Chapter 175M and 458 CMR 2.00) Investigate, analyze, and respond to complex claims filed by claimants seeking DFML benefits that have been escalated from the call center and/or internal DFML departments and staff and research inconsistencies or omissions in reports generated by the agency and/or agency partners computer systems. Identify discrepancies or issues and escalate or remand to the appropriate internal department. Collect and review available data to identify, prioritize, and resolve atypical eligibility issues. Write clear, logical written decisions based on relevant laws, rules, and regulations. Review applicant data in cases where client eligibility or suitability is questionable or difficult to determine. 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. Determine validity of information received through the Program Integrity's data match initiatives related to identity and eligibility, and issues written determinations on the same. Advise claimants and employers of appeal rights and procedures. Maintain relationships/contact with appropriate department personnel. Prepare reports, attend meetings, and drafts correspondence. Assist in performing system testing/reporting as required. Intake reports of potential fraud through the Department’s Fraud Hotline. Investigate cases of alleged fraud committed by claimants against the Agency. Analyze and investigate information received on employer information requests from employers. Process requests for hearings. Update Appeal Log accurately and in accordance with established policy and procedure. Performs related duties as required and assigned.

Requirements

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 gather information.
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/accounting calculations.
Ability to meet deadlines in a timely and accurate manner.
Ability to establish rapport and deal effectively with persons from different ethnic, cultural, and/or economic backgrounds.
Ability to interact empathetically with people who are under physical and/or emotional stress.
Ability to deal tactfully with others.
Ability to establish and maintain harmonious working relationships with others.
Ability to give oral and written instructions in a precise, understandable manner.
Ability to identify issues and propose actionable solutions.
Ability to maintain accurate records.
Ability to make decisions and act quickly in stressful situations.
Ability to exercise discretion in handling confidential information.
Ability to exercise sound judgment.
Ability to work independently.
Applicants must have (A) at least two (2) years of full time, or equivalent part-time professional or paraprofessional experience in personnel interviewing, vocational counseling, employment counseling, rehabilitation counseling, educational counseling, credit collection, credit interviewing, credit investigation, claims adjudication, claims settlement, claims examining, claims, investigation, claims interviewing, social work or social casework, or (B) any equivalent combination of the required experience and the substitutions below.

Responsibilities

Facilitate the program integrity of the DFML by ensuring claims filed with the Department of Family and Medical Leave (DFML) are consistent with applicable laws, regulations, and policies (M.G.L. Chapter 175M and 458 CMR 2.00)
Investigate, analyze, and respond to complex claims filed by claimants seeking DFML benefits that have been escalated from the call center and/or internal DFML departments and staff and research inconsistencies or omissions in reports generated by the agency and/or agency partners computer systems.
Identify discrepancies or issues and escalate or remand to the appropriate internal department.
Collect and review available data to identify, prioritize, and resolve atypical eligibility issues.
Write clear, logical written decisions based on relevant laws, rules, and regulations.
Review applicant data in cases where client eligibility or suitability is questionable or difficult to determine.
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.
Determine validity of information received through the Program Integrity's data match initiatives related to identity and eligibility, and issues written determinations on the same.
Advise claimants and employers of appeal rights and procedures.
Maintain relationships/contact with appropriate department personnel.
Prepare reports, attend meetings, and drafts correspondence.
Assist in performing system testing/reporting as required.
Intake reports of potential fraud through the Department’s Fraud Hotline.
Investigate cases of alleged fraud committed by claimants against the Agency.
Analyze and investigate information received on employer information requests from employers.
Process requests for hearings.
Update Appeal Log accurately and in accordance with established policy and procedure.
Performs related duties as required and assigned.

Benefits

Comprehensive Benefits
When you embark on a career with the Commonwealth, you are offered an outstanding suite of employee benefits that add to the overall value of your compensation package. We take pride in providing a work experience that supports you, your loved ones, and your future.
Want the specifics? Explore our Employee Benefits and Rewards!

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