State of Washington Classified Job Specification
PAID FAMILY & MEDICAL LEAVE SPECIALIST 1
Class Series Concept
This series is responsible for review and analysis of information obtained through source documents and client/customer interviews to ensure compliance with the Paid Family & Medical Leave (PFML) standards. Positions in this series are responsible for verifying employers’ financial records and beneficiaries’ medical documentation. These positions collect and process PFML premiums from employers, perform claims processing, audit employers for compliance, investigate employers and beneficiaries for fraud and represent the agency through the administrative hearings process.
This is the entry level classification for the professional PFML series. Under close supervision, performs basic and routine professional duties related to PFML insurance programs and services.
Incumbents develop a working knowledge of first-level professional PFML assignments, including processing basic and routine claims, conducting interviews, reviewing applications and documents to determine initial eligibility for PFML benefit(s) and collecting premiums from employers participating in the PFML program.
Tasks are typically recurring and limited in scope. Assignments require basic analysis of a variety of applicable state and federal laws, regulations and policies. Scope of work is within established PFML standards.
Assists employers in the use of electronic filing and payment methods;
Explains appeal rights and applicable laws and policies;
Interviews clients/customers, analyzes written and oral information, and determines eligibility for PFML benefits; assesses client/customer immediate need in emergent situations; implements case closures per compliance regulations, policies, and changes in clients' eligibility;
Obtains and reviews necessary data, such as employer premium/wage reports;
Explains program requirements and services available;
Refers client/customer to both mandatory and optional services and to other agencies as required;
Resolves routine client/customer problems by identifying the issues, determining procedural steps necessary to bring resolution, working with program staff to implement resolution, and communicating results to the client/customer;
Reads and interprets Washington Administrative Codes and procedural manuals;
Registers new businesses, utilizing an automated system; updates information on businesses already on the automated system;
Makes changes and updates information in beneficiary and employer accounts to ensure accuracy; creates and manages beneficiary and employer profiles and maintains integrity of the data and information while delivering PFML services;
Collects premiums from employers participating in the PFML program;
Processes and adjudicates routine claims;
Detects discrepancies and clarifies data through telephonic and electronic inquiries, correspondence, and interviews; recognizes and re-calculates incorrect payments of benefits and established overpayments;
Reviews initial claims for PFML benefits; determines the need to obtain additional medical documentation or supporting evidence from medical and non-medical providers;
Prepares written correspondence to medical and non-medical providers of information and conducts basic investigative telephonic interviews with these providers when necessary;
Performs other duties as required.
Knowledge and Abilities
Knowledge of: fundamentals of customer service and person-to-person communication; office practices and procedures; business English and letter writing; spelling and basic arithmetic.
Ability to: develop interviewing skills; learn to interpret and analyze data in accordance with established procedures; learn agency services; learn and understand the motivations for human behavior in order to work effectively with members of the public and co-workers.
There may be instances where individual positions must have additional licenses or certification. It is the employer’s responsibility to ensure the appropriate licenses/certifications are obtained for each position.
A Bachelor's degree in a health or social science, public administration or a related field
Four years of experience examining and/or processing loan applications, medical insurance or rehabilitation claims, insurance claims, collection of insurance premiums, tax collection or providing staff support in financial eligibility determination
A combination of education and/or relevant experience.
Class Specification History
New class adopted 5/17/2018, effective 5/18/2018.