Lead Claims Examiner - Job Service Rep II

Lead Claims Examiner/Job Service Representative II

The Program Integrity Claims Examiner/Job Service Representative II is responsible for supporting processes within the Department of Family Medical Leave (DFML). The Lead Claims Examiner/Job Service Representative II will review, analyze and evaluate disputed claims to ensure uniformity with PFML statute and regulations by analyzing fact-finding, data and information, ensure that the required information has been obtained accurately and completely and that the determinations confirm that proper adjudication procedures have been followed throughout the determination process to ensure that appropriate internal procedures were followed. Provide technical assistance and guidance to Job Service-Representative I's on fact-finding and the resolution of case issues. Interpret and explain relevant laws, regulations, policies and procedures as required to ensure effective operations and compliance with existing established procedures. Make determinations on eligibility for benefits escalated to DFML operations in accordance with PFML Statute and Regulations.

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.

Lead Claims Examiner/Job Service Representative II, who reports to the Senior Manager of Benefit Operations & Program Integrity is based in Boston, MA, and is responsible for the following:

• Provides technical assistance, guidance and counsel to agency staff, managers, and others on fact-finding, the resolution of PFML case issues and procedural questions concerning eligibility for PFML benefits in order to insure consistent interpretation of the law.
• Reviews escalated PFML applications involving employer conflicts on claims and analyzes all fact-finding, data and information to ensure that the required information has been obtained accurately and completely and properly adjudicates the application based on department operational procedures, statutory and regulatory requirements.
• Conducts regular case reviews and discussions with Job Service Representative I's to develop and enhance their capacity and ability to conduct complete and accurate fact finding and make appropriate determinations.
• Conducts both informal and formal quality reviews of the work of Job Service Representative I's to evaluate quality and identify improvement opportunities.
• Provides training to Job Service Representative I's to enhance their knowledge of the Paid Family and Medical Leave, Regulations, Policies, and Procedures and their ability to apply this knowledge effectively to application determinations.
• Participates in work groups to develop and enhance procedures for implementing new laws and regulations.
• Interprets and explains relevant laws, regulations, policies and procedures as required to ensure effective operations and compliance with existing established procedures.
• Gathers data & writes reports on performance quality & corrective action recommendations.
• Helps to update standard operating procedures in coordination with current operational protocols when system enhancements or new regulations are added.
• Provides information on Department of Paid Family and Medical Leave to employers, claimants and the general public through webinars, stakeholder meetings, correspondence and by the telephone.
• Performs related duties such as preparing written reports, maintaining records and data interpretation.
• Performs related miscellaneous duties as required and assigned.

Why should you join DFML?

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.

Who you are

We're seeking candidates who have:

• Ability to relate in a positive manner with claimants, employers, agency staff members and others in eliciting all necessary information to issue claim determinations.
• Ability to exercise strong technical knowledge of agency, federal and state laws, rules, regulations, codes, policies and procedures governing DFML in order to examine and resolve most complex DFML applications.
• Experience in adjudicating claims.
• Ability to write concisely to express thoughts clearly and develop ideas in a logical sequence.
• Ability to understand, explain and apply the laws, rules and regulations, policies and procedures governing agency activities.
• Ability to exercise discretion in handling confidential information.
• Ability to work under narrow time constraints.
• Ability to negotiate solutions to complex problems.
• Ability to interpret variety of instructions in written, oral, picture or schedule form.
• Ability to define problems, collect data, establish facts and draw valid conclusions.
• Knowledge of work simplification methods.
• Ability to supervise, including planning and assigning work according to the nature of the job to be accomplished, the capabilities of subordinates and available resources; controlling work through periodic reviews and/or evaluations; determining subordinates training needs and providing or arranging for such training; motivating subordinates to work effectively; determining the need for disciplinary action and either recommending or initiating disciplinary action.
• Ability to adjust to varying or changing situations to meet emergency or changing program requirements.

First consideration will be given to those applicants that apply within the first 14 days. Minimum Entrance Requirements: Applicants must have (A) at least three (3) 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 two (2) years of the required experience. III. A Master's or higher degree 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.