Paid Family Leave Claims Examiner
Government of the District of Columbia
233 reviews
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Washington, DC 20019
$82,326 - $105,339 a year
Government of the District of Columbia
233 reviews
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This position is located in the Office of Paid Family Leave (OPFL) located in the Department of Employment Services (DOES). This position reviews and assesses claim submissions during the OPFL Benefits adjudication process. This position will review, investigate, analyze, and make determinations on monetary and nonmonetary issues, examine medical certifications, conduct reconsiderations, and evaluate the validity of claims for Paid Family Leave benefits payments. The position will process and document claims to ensure compliance with legislative provisions and act in a fiduciary role on behalf of the District.
Duties and Responsibilities
The incumbent will review, examine, investigate, and adjudicate the full range of Paid Family Leave claims. Will verify work performed by other claims examiners and act as the lead claims examiner to assess errors, deficiencies in the adjudication process, and identify recommended solutions. Contacts claimants, employers, medical providers, and conducts in-person interviews with any necessary parties in the investigation and processing of a claim in order to verify factual information, including wage information needed to properly adjudicate claims and administer benefits. Interviews and assists individuals regarding erroneous claims against the District of Columbia.
Determines whether all statutory requirements relating to eligibility and entitlement for benefits were met during the review and processing of a Paid Family Leave benefits claim. Writes justifications to support conclusions and final determinations reached in the adjudication process.
Processes assigned claims for payment or denial in accordance with established procedures and guidelines in a timely manner and meeting departmental quality/production standards. Escalates monetary, non-monetary, medical, and reconsideration issues on a claim as needed to supervisory claims examiners, management, the Chief of Benefits and/or executive level management. Detects missing wage records or errors in the monetary eligibility process, and conducts the necessary wage investigation, in coordination with the Paid Family Leave Tax Division, to capture reportable wages and make the necessary corrections to a claimant’s file in order to effectively issue a final determination on a claim.
Ensures that all determinations on a claim are adequate and in compliance with the applicable laws, rules and regulations, policies, procedures, precedents and other pertinent criteria under the Universal Paid Leave Amendment Act.
Sends notices and correspondences to claimants, employers, and medical providers concerning Paid Family Leave claims and investigations. Devises appropriate methods for securing the required information such as fact-finding forms, questionnaires and other tools or methods to acquire pertinent data/information. Recommends preventative and corrective actions to improve program processes, deficiencies, directives, and guidelines. Operational changes recommended could impact Standard Operating Procedures (SOPs), staffing levels, and organizational structures within the program.
Responsible for the preparation and development of statistical and narrative reports, memorandums, close-out reports, and other supporting documentation to summarize productivity, performance, issues, and goals/objectives in order to ensure the effective processing of Paid Family Leave claims. Ability to recognize fraudulent or irregular information. Refers claims as authorized to the appropriate office for further investigation, final issuance of a determination and/or legal review. Provides superior customer service to internal and/or external stakeholders. Reviews and provides specific information to questions/concerns from all key stakeholders concerning the Paid Family Leave program. Collects and address customer feedback, meets customer needs and demonstrates flexibility and responsiveness.
Responds to general information inquiries regarding Paid Family Leave Benefits and pertinent policy-related matters to the agency or program.
Identification and reporting of system errors to the appropriate program and vendor stakeholders, as well as performing testing to resolve the system errors.
Ability to provide training to lower-level staff or equivalent.
Performs other related duties as assigned.
Qualifications
Degree from accredited four-year college or university preferred.
AND
Working knowledge of the Universal Paid Family Leave Act and other related laws, rules, regulations, and guidelines. Advanced ability to communicate effectively both written and orally. Knowledge of established policies and procedures. Knowledge of interview techniques and ability to follow leads. Knowledge of the Paid Family Leave Tax and Benefit Administration systems. Ability to recognize fraudulent or irregular information.
Licensures and Certifications
None
Work Conditions/Environment
The work is performed in a normal office setting.
Promotion Potential
None
Other Significant Facts
Promotion Potential: No known promotion potential
Duration of Appointment : Career Service Term: 13 Month
Pay Plan, Series, Grade: CS-0998-12
Collective Bargaining Unit (Union): This position is covered by AFGE Local 1000
Position Designation: This position has been designated as Security sensitive therefore the incumbent of this
position will be subject to enhanced suitability screening pursuant to Chapter 4 of DC Personnel Regulations,
Suitability and as such, incumbents of this position shall be subject to criminal background checks,
background investigations, and mandatory drug and alcohol testing, as applicable.
EEO Statement: The District of Columbia Government is an Equal Opportunity Employer. All qualified candidates will receive consideration without regard to race, color, religion, national origin, sex, age, marital status, personal appearance, sexual orientation, family responsibilities, matriculation, physical handicap, or political affiliation.
If the position you are applying for is in the Career, Management Supervisory, or Educational Service at an annual salary of one hundred fifty thousand dollars ($150,000) or more, you must establish residency in the District of Columbia within one hundred eighty (180) days of the effective date of the appointment and continue to maintain residency within the District of Columbia throughout the duration of the appointment.
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