Claim Management: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. Collaboration & Escalation: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. Compliance & Quality Assurance: - Ensure all claims are handled in compliance with State regulations, HIPAA, and other applicable regulations. - Participate in audits, quality reviews, and continuous improvement initiatives. QUALIFICAITONS: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. Compensation.