Ability Analyst Paid Family Medical Leave

Ability Analyst - C410AN

Sr Ability Analyst - C409AN

We're determined to make a difference and are proud to be an insurance company that goes well beyond coverages and policies. Working here means having every opportunity to achieve your goals - and to help others accomplish theirs, too. Join our team as we help shape the future.

This role requires strong analytical expertise, strategic thinking, and communication skills to accurately adjudicate PFML claims. As Ability Analyst, you will play a critical role in supporting individuals during some of the most challenging times in their lives. You will be responsible for managing a caseload of PFML claims of moderate complexity, ensuring each claim is handled with empathy, accuracy, and efficiency. This role requires a balance of analytical thinking, customer service, and regulatory compliance. You will serve as the primary point of contact for claimants, employers, and medical professionals, guiding them through the claims process and ensuring timely and fair outcomes. Your work will directly impact the financial and emotional well-being of our customers. This role can be filled as a T10 or T09 based on experience.

• Independently manage a caseload of PFML claims from intake through resolution.
• Conduct thorough reviews of medical records, employment history, and policy provisions.
• Determine eligibility and benefit entitlement based on contractual language and supporting documentation.
• Customer Communication:
• Serve as the main contact for claimants, providing clear, compassionate, and timely updates.
• Communicate with employers, physicians, and legal representatives to gather and clarify information.
• Educate claimants on the PFML process, timelines, and expectations.
• Decision-Making & Documentation:
• Make well-reasoned decisions supported by evidence and aligned with policy terms.
• Document all claim activity, rationale, and communications in a clear and professional manner.
• Prepare written correspondence including approval, denial, and status letters.

• Collaborate with internal resources such as peers, CRO, SIU and Team Leader
• Escalate complex or high-risk claims to senior team members or management as appropriate.

• • Ensure all claims are handled in compliance with State regulations, HIPAA, and other applicable regulations.
• • Participate in audits, quality reviews, and continuous improvement initiatives.

• Bachelor's degree or equivalent work experience in insurance claims adjudication, healthcare, or a related field preferred
• THAA experience preferred.
• Ability to understand State regulations, compliance requirements and medical terminology.
• Ability to recognize red flags and escalate high-risk or potentially fraudulent claims appropriately.
• Excellent analytical, organizational, and time management skills.
• Proven ability to multitask effectively in a fast-paced, deadline-driven environment.
• Demonstrated problem-solving skills with the ability to think critically and make sound decisions, drive solutions and overcome challenges.
• Strong interpersonal skills and a team-oriented mindset, with the ability to collaborate across departments.
• Exceptional written and verbal communication abilities.
• Proficiency in claims management systems