Claims Consultant

Tata Consultancy Services is seeking a Claims Consultant to manage Absence case management and claim adjudications. The role involves reviewing medical documentation, determining benefits, and ensuring timely payments and adjustments for various claims.

Responsibilities:

• To provide Absence case management and claim adjudications, based on medical documentation and the applicable Disability/FMLA/Paid Family Leave interpretation, including determining benefits due and making timely payments and adjustments
• Review and analyze the claim nuances, eligibility review, and type of claims (intermittent or continuous)
• Review and analyze medical information (i.e. attending physician reports, medical records such as diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined
• Approval or denial on FMLA claims as per Insurance carrier, and employer’s guidelines
• Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to US paid family law regulations
• Review claims for Not in good order cases, and work on securing missing documentations including employee, physician, or employer outreach
• Communicates clearly with the claimants and clients to set expectations on all aspects of claims process either by phone and/or written correspondence
• Reviews client critical deliverables, manages the overall workload, and second-level process escalation
• Determines benefits due, makes timely claims payments/approvals and adjustments for Workers Compensation, State Short Term Disability, and other disability offsets
• Refers cases as appropriate to team lead and clinical case management
• Responsible for managing the day-to-day workload and first-level process escalation, and reviews processes for accuracy and timeliness where applicable in case of peer reviews
• Provide ideas to management on continuous improvement and service level management
• Performs other duties or participates in special projects as assigned