Claims Examiner - Job Service Rep I

Claims Examiner / Job Service Representative I

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.

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.

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.

The idea of working for a "government startup" excites you. You want to work for a place that values your contributions and ideas, moves quickly in implementing solutions, and at the same time, allows you the flexibility to have a good balance between your personal and professional life. You will work with a dedicated team who are fueled by our mission of helping the people of the Commonwealth smoothly navigate our program during the big moments in their lives and will value you as both a coworker and as a person.

We're seeking candidates who have :

First consideration will be given to those applicants that apply within the first 14 days. 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.

Substitution : I. An Associate's degree may be substituted for one (1) year of the required experience. II. A Bachelor's degree or higher may be substituted for the required experience.

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!

An Equal Opportunity / Affirmative Action Employer. Females, minorities, veterans, and persons with disabilities are strongly encouraged to apply. The Commonwealth is an Equal Opportunity Employer and does not discriminate on the basis of race, religion, color, sex, gender identity or expression, sexual orientation, age, disability, national origin, veteran status, or any other basis covered by appropriate law. Research suggests that qualified women, Black, Indigenous, and Persons of Color (BIPOC) may self-select out of opportunities if they don't meet 100% of the job requirements. We encourage individuals who believe they have the skills necessary to thrive to apply for this role.

Job : Community and Social Services Organization : Department of Workforce Development Title : Claims Examiner - Job Service Rep I Location : Massachusetts-Boston-100 Cambridge Street