See Paid Family and Medical Leave Specialist 1.

This is the senior, specialist or lead worker for the professional Paid Family & Medical Leave (PFML) Specialist series. Reviews appeal requests, represents the agency in the appeal process and makes recommendations to management on appeal cases. These positions serve the majority of the time in one of the following capacities:  

1. Designated lead worker for an assigned unit of PFML Specialists

2. Designated trainer

3. Designated business compliance auditor and/or investigator

As the senior, specialist or lead worker, performs assignments that require in-depth knowledge to make decisions on complicated issues. These assignments often require proactive intervention and have wide or precedent setting impact. Provides advice and consultation to agency management, lower level professional staff and peers. Handles or oversees the division’s most sensitive, complex or critical PFML issues. Provides advice and guidance and/or leads professional or other staff.

As Lead Worker: 

Performs the work of PFML Specialist 2s;  

Conducts complex collection activity of PFML rules and regulations; 

Interprets and explains applicable state and federal laws, regulations and policies to employers and clients participating in the program; 

Reviews casework of lower level PFML Specialists to ensure accuracy and conformance to laws, regulations, policies and procedures; 

Conducts research and analysis of claim history and supporting documentation in order to identify whether or not claims were adjudicated correctly; 

Provides expert technical assistance to internal and external client/customer; 

Provides staff with expertise and assistance in the most complex claim issues;  

Consults with agency management on client/customer relations issues; recommends changes to agency procedures to enhance access to agency services;  

Resolves 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; 

Reviews policy and provides procedural clarification and consultation; performs complex case review and problem resolution; provides statewide policy and procedure development input and consultation;  

Develops, schedules, and conducts orientation programs for new employees on department regulations and procedures, casework principles and methods, caseload management, community resources, individual and group behavior, and interviewing skills;  

Performs other duties as required.

As a Trainer: 

Designs, creates, and updates lesson plans, student handbooks, assessments, handouts, trainer guides, and other materials for instructor led training; develops and secures PFML training materials, maintains training library; keeps informed of current training practices and materials;   

Participates and/or facilitates subject-matter-expert groups to identify training needs;  

Advises and assists PFML management in planning and conducting local training programs; develops recommendations for management on training needs, assessments, and issues;

Develops, schedules, and conducts training on new policies and procedures and new state regulations or requirements for PFML program services;

Performs the work of PFML Specialist 2s;  

Performs other duties as required.

As Designated Business Compliance Auditor and/or Investigator:

Conducts quality assurance audits; reviews casework to ensure accuracy and conformance to laws, regulations, policies, and procedures;  

Reviews responses to quality assurance audits, as required by legal, statutory or legislative requirements; reviews and approves corrective action plans;  

Investigates possible fraud and employer irregularities with PFML premium collections and reporting; 

Investigates healthcare providers and claimants for PFML irregularities and possible fraud; 

Reviews investigative reports for thoroughness, accuracy, clarity and conciseness, ensuring compliance with established PFML investigations policy and procedures;  

Monitors PFML staff processes in meeting applicable state and federal laws, regulations and policies;  

Detects error trends and identifies training needs; coordinate with PFML Trainer for the required training; 

Processes requests for administrative hearings/appeals;  

Conducts pre-hearing conferences; 

Makes necessary contacts with staff, agencies, and health care providers to prepare the department's case for presentation at the hearing;  

Represents the department in the administrative hearing; 

Investigates, prepares documentation and recommends position on grievances, complaints and appeals;  

Records appeal decision in electronic filing system; 

Works with management to enact findings by the Office of Administrative Hearings (OAH); 

Makes recommendations to management to appeal or petition for review of adverse decisions received from OAH; 

Implements the administrative hearing decision; 

Consults with agency management on client/customer relations issues; recommends changes to agency procedures to enhance access to agency services;  

Resolves 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; 

Performs other duties as required.

Knowledge of: PFML service programs, applicable state and federal laws, regulations and policies, principles, problems, and practices of PFML program administration; principles of individual and group behavior, social behavior, social and economic conditions, and their effects upon individuals; office procedures and practices; leading subordinate employees. 

Ability to: make independent conclusions and decisions; evaluate and recommend changes to PFML program management; work cooperatively with staff, 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; express ideas clearly; direct and assist others in interpretation and analysis of data; lead and train staff.

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 2 

OR 

A Bachelor’s degree in a health or social science, public administration or a related field and two 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 

OR  

A Master’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 2 with another state that administers a paid family medical leave program.