Absence Claims Case Manager I

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Evaluate and medically oversee Short Term Disability and absence claims.

• Manage claims in conjunction with FMLA, State Paid Medical Leave, and State Paid Disability.

• Analyze contract terms, plan design, medical details, and regulatory standards.

• Convey claim status and decisions via telephone and written communication.

• Reach out to claimants, healthcare providers, employers, and planholders to collect information and evaluate job accommodations.

• Identify claim-related issues and formulate, implement, and modify action plans as necessary.

• Determine coverage, eligibility for benefits, disability status, insured earnings, offsets, underpayments, and overpayments.

• Assess occupational requirements, medical documentation, payroll details, and income sources.

• Review and verify AI-generated claim recommendations, data extractions, draft correspondence, and highlighted discrepancies.

• Create and document claim action plans, including strategies for returning to the claimant’s previous job.

• Utilize Medical Disability Guidelines and other disability assessment tools to gauge claim duration.

• Support return-to-work initiatives and job-accommodation possibilities.

• Recover overpayments or negotiate payment plans.

• Evaluate restrictions and limitations while fostering a suitable partnership with PRT.

• Fulfill turnaround time, quality assurance, customer experience, compliance, and audit-readiness objectives.

• Report directly to the Team Leader, STD/Absence.

⛳️ Requirements

• Bachelor’s degree is preferred, though not mandatory.

• Strong mathematical skills, including the ability to calculate benefits and review payroll or income data.

• Proficient in critical thinking, problem-solving, analytical reasoning, sound judgment, and decision-making.

• Capability to interpret medical data, contract language, plan provisions, and regulatory guidelines.

• Ability to prioritize tasks and manage multiple assignments across various business applications.

• Capacity to work independently within defined procedures while also thriving in a collaborative team setting.

• Excellent verbal and written communication skills, maintaining professionalism.

• Skill in managing various priorities and adhering to departmental turnaround timelines.

• Resilience and flexibility in a fast-paced, high-volume claims environment.

• Strong customer service abilities.

• Proficiency in Microsoft Windows applications, including Microsoft Word, Excel, and Outlook.

• Experience with AI/Copilot prompting is preferred.

• Ability to review and validate AI-generated recommendations, data extractions, and correspondence.

• Commitment to data quality assurance and attention to detail, ensuring completeness, accuracy, compliance, and audit-readiness of claim files.

• Successful completion of a job-related assessment is required.

• Experience in Group Benefits is preferred, including Short Term Disability, Statutory Paid Leave, Family Medical Leave, or related fields in the insurance industry, regulatory compliance, or equivalent professional background.

• Must be legally authorized to work in the United States without current or future employer sponsorship.

🏝️ Benefits

• Full-time eligible employees receive a comprehensive array of company benefits and resources.

• Opportunities for skill development.

• Leadership development initiatives.

• Philanthropic engagement opportunities.

• Modern, supportive, flexible, and inclusive benefits and resources.

• Reasonable accommodations available for qualified individuals with disabilities.

• Options for remote work arrangements.

• Potential eligibility for annual bonuses, sales incentives, or other performance-based compensation.