See Paid Family and Medical Leave Specialist 1.

This is the journey level classification for the professional Paid Family & Medical Leave (PFML) Specialist series. Under general direction, processes and adjudicates complex claims related to PFML insurance programs and services.

Incumbents work independently and provide professional PFML services. Work performed is complex and positions at this level make decisions and judgments within established PFML standards.

Makes complex judgements and payment/adjustment determinations using established fee schedules, applicable state and federal laws, regulations and policies, processes edits coded by policy guidelines; 

Resolves complex 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; 

May be required to oversee the training of lower level staff; 

Documents and verifies the recipients’ reason/explanation for requesting PFML benefits;  

Collects premiums from employers participating in the PFML program;  

Processes and adjudicates claims;  

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; 

Initiates and answers correspondence concerning unique and complex problems relating to eligibility; 

Performs other duties as required. 

Knowledge of: PFML service programs, applicable state and federal laws, regulations and policies; office procedures and practices; interviewing techniques, letter and report writing; cultural diversity, principles of individual and group behaviors, social behaviors, social and economic conditions and their effects upon individuals; other community programs providing financial and health services. 

Ability to: make independent conclusions and decisions; evaluate and recommend changes to PFML program management; work cooperatively with members of the public and with co-workers; practice tact, courtesy and discretion; accurately document, listen, observe, communicate, confront and engage in problem solving and conflict resolution; convey interest and concern to clients requesting information or assistance with problems related to PFML programs and services.

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.

One year as a PFML Specialist 1 

OR 

A Bachelor's degree in a health or social science, public administration or a related field; and one year 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 

OR 

A combination of education and/or relevant experience 

OR 

One year of experience equivalent to the PFML Specialist 1 with another state that administers a paid family medical leave program.