CASE SPECIALIST JOB DESCRIPTION

A Case Specialist manages the end-to-end adjudication of disability and leave claims on behalf of policyholders and their employees. The role owns final determination authority - approving, denying, or routing claims within established liability limits - under regulatory frameworks including FMLA and state-specific short-term disability statutes. That authority is narrow and consequential. Errors in contract interpretation or eligibility assessment directly affect benefit payments owed to claimants, making precision and policy fluency non-negotiable in this seat.

As the Case Specialist, you administer Group Short-Term Disability and FMLA leave claims from intake through resolution, applying federal and state regulatory requirements to each determination with accuracy and timeliness. You operate within a structured claims unit, supporting policyholders, claimants, and medical resources while adhering to carrier liability guidelines and documented workflow procedures.

Career Impact: Hands-on authority over STD and FMLA claim determinations builds specialist credibility within the employee benefits and disability insurance market that generalist customer service roles do not offer.

Business Impact: Policyholders and claimants depend on timely, accurate determinations - delays or misadjudications create direct financial liability for carriers and erode employer trust in the benefit program.

Growth Opportunity: Proficiency in multi-state disability statutes and FMLA compliance opens advancement paths toward Senior Claims Examiner, Leave Administrator, or MGA support roles with broader policy placement scope.

Company Value: This role operates in a team environment that combines independent case ownership with collaborative support structures, including access to medical resource consultants and technical assistance from senior claims staff.

• Adjudicate STD and FMLA claims against applicable policy provisions, determining eligibility and approving or denying benefits within authorized liability limits.
• Review medical documentation and evaluate recommendations from clinical resources to determine appropriate claim disposition.
• Develop action plans for each assigned case to ensure determinations are completed accurately and within contractual timeliness standards.
• Interpret group insurance contracts and leave plan documents to ensure consistent application of policy terms across all claim decisions.
• Obtain supporting documentation from employers, claimants, physicians, hospitals, and attorneys to substantiate claim status or resolve outstanding issues.
• Administer leave follow-up activities including health condition recertification, intermittent claim tracking, and return-to-work confirmation.
• Process new business applications and manage underwriting documentation for broker-submitted cases within established MGA workflows.
• Maintain accurate system records reflecting current claim and leave status, with complete diary documentation at each case milestone.

• Bachelor's degree in Business, Finance, Human Services, or a related field, or equivalent work experience.
• 2 or more years of claims, benefits administration, or financial services experience, with demonstrated exposure to disability or leave products.
• Working knowledge of FMLA regulations and state short-term disability statutes governing eligibility and benefit calculations.
• Ability to interpret insurance contracts and apply policy provisions accurately to individual claim scenarios.
• Strong mathematical aptitude for payment calculations, liability assessments, and claims adjustment.
• Proven organizational skills with the ability to manage a multi-case workload under competing deadlines without loss of accuracy.
• Effective written and verbal communication skills for interaction with claimants, employers, medical providers, and legal contacts involving confidential information.

• Experience processing Group Short-Term Disability claims within a carrier or third-party administrator environment.
• Familiarity with Managing General Agency workflows, including broker relationship management and policy placement processes.
• LOMA coursework or equivalent insurance industry education demonstrating foundational product knowledge.
• Prior exposure to medical terminology, CPT coding, or clinical documentation review in a claims or benefits context.

• Claim determination turnaround time against contractual SLA thresholds, measured per case.
• Adjudication accuracy rate, tracking decisions overturned on appeal or audit review.
• Leave recertification completion rate within required notice windows under applicable FMLA timelines.
• Caseload throughput per period, reflecting consistent management of assigned STD and leave files.
• Documentation compliance rate, measuring completeness of diary entries and system updates per case milestone.
• Typical tools: claims administration platforms (commonly group disability or leave management systems); productivity software (commonly spreadsheet and word processing applications).

• Base Salary Range: $42,000 to $62,000 annually, varying by market and seniority.
• Bonus: Annual performance bonus, typically 5% to 10% of base salary.
• Equity: Not standard for this level in insurance operations roles.
• Health Benefits: Medical, dental, and vision coverage; employer contribution standard.
• PTO: 15 to 20 days annually, plus standard federal holidays.
• Common Perks: Professional development reimbursement for LOMA or industry coursework; flexible scheduling within coverage hours.

Figures are estimates based on general US market benchmarks and may be outdated. Adjust based on location, company size, and seniority level.

Successful completion of a background check, which may include verification of employment history and criminal record review, is a condition of employment. All qualified applicants will receive consideration without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other characteristic protected under applicable federal, state, or local law. Reasonable accommodations are available to applicants and employees with disabilities throughout the hiring process and employment. Candidates must be authorized to work in the United States.

The Case Specialist owns the professional management of both routine and complex Group Short Term Disability claims, reviewing submissions and making final determinations for admittance or denial within established Company liability limits. Working both independently and in a team, the Case Specialist serves policyholders and claimants directly, enabling accurate and timely claim adjudication that upholds consistent, fair claims practices.

Key Responsibilities

• Review claim payments within established limits and evaluate recommendations from medical resources to determine proper disposition.
• Set claim action plans to ensure determinations are adjudicated in a timely, accurate, and efficient manner.
• Interpret contracts and ensure consistent, fair claims practices and adherence to applicable laws, regulations, and procedures.
• Obtain backup documentation by communicating with agents, employers, claimants, hospitals, physicians, attorneys, and other resources as necessary.
• Handle other related duties such as providing technical assistance to Claims staff or assisting in special projects as business needs arise.

Core Functions

• Associate's or Bachelor's degree would be an advantage.
• 1–2 years of customer service or financial services experience.
• Claims experience would be a distinct advantage.
• Strong mathematical skills for calculations and adjustment of claim payments.
• Proficiency in MS Office (Outlook, Word, Excel, PowerPoint) and Windows 7, with ability to learn new and complex computer systems.
• Strong organizational skills, ability to multi-task, and exercise independent judgment to settle claims in accordance with policy provisions.
• Excellent analytical, problem-solving, customer service, and written and verbal communication skills, with the ability to handle confidential information.
• Reliable, predictable full-time attendance including timely arrival is an essential function of this role.

Reporting to the Recovery Unit leadership, the Case Specialist delivers recovery of Medicaid and public assistance payments from liable third parties by researching federal and state statutes, maintaining assigned caseloads, and negotiating settlements within CHCF guidelines. Partnering with probate courts, attorneys, hospitals, and insurance companies, the Case Specialist ensures Medicaid programs remain the payor of last resort while protecting program integrity under TITLE XIX regulations.

Duties

• Refine and enhance current operations and implement innovative methods to identify new cases, verify claims, and recover payments from all liable third parties.
• Research, maintain, and apply all relevant federal and state statutes and regulations pertaining to Third Party Recovery to ensure Medicaid and related programs are payors of last resort.
• Maintain an assigned caseload following established protocols, identify benefits paid by Medicaid, and calculate total recovery value per case.
• Negotiate, settle, and collect from liable third parties within federal and state statutes, regulations, and Medicaid guidelines while adhering to all CHCF procedures.
• Represent the best interest of the Medicaid program consistent with CHCF goals and objectives.
• Request and produce claims history printouts and service reports from Medicaid history databases for recipient payment history.
• Investigate and document all case-related financial and medical history to support claims against probate estates or third-party settlements.
• Communicate and collaborate with probate courts, attorneys, hospitals, and insurance companies to ensure all Medicaid Casualty Recovery cases are referred and processed accordingly.
• Conduct legal research using public databases and web-based applications, and prepare legal memoranda and case-related documents for referral to Medicaid EHS legal department.
• Provide training to support staff, maintain and update the Recovery Unit training manual, and maintain all case records for the required retention period.

Qualifications & Experience

• Bachelor's Degree in Business Administration or equivalent experience.
• Paralegal certificate.
• 3 years of related experience; Third Party Recovery or collections experience preferred.
• Knowledge of State statutes and federal regulations related to Third Party Recovery; understanding of TITLE XIX (Medicaid/State Plan) programs, laws, and regulations.
• Familiarity with insurance billing, claims inquiry, accounts receivable, and collections processes.
• Understanding of medical and legal terminology, medical billing, diagnosis and procedure codes, and general medical conditions; previous experience with workers compensation, tort recovery, motor vehicle accidents, medical malpractice, general liability, and class actions preferred.
• Proficient in Microsoft Office, web-based solutions, and scanning software.
• Strong oral and written communication, effective negotiation, and strong interpersonal skills.
• Ability to work professionally with Medicaid staff and other agencies related to third-party recovery.

Sitting at the intersection of direct family intervention and community resource coordination, the Case Specialist / Parent Aid conducts weekly home visits for a caseload of 12+/- DCF families and 2–3 housing or homelessness cases, developing family goal plans and delivering wraparound services under the 4-stage parent-aide model. Operating across the Department of Children and Families, community organizations, and housing programs, this role enables families to build sustainable coping, parenting, and life skills while maintaining child safety and regulatory compliance.

Functions

• Maintain a caseload of 12+/- DCF families and 2–3 community cases, conducting weekly home visits or meetings in appropriate environments.
• Help families identify strengths, natural and community supports, and develop coping, decision-making, parenting, and organizational skills using the 4-stage parent-aide model.
• Develop family goal plans for clients experiencing trauma, mental health issues, substance abuse, domestic violence, homelessness, or child abuse and neglect.
• Conduct supervised visits and facilitate Parenting Education Groups.
• Work with homeless consumers on money management, resources, employment, coping skills, and healthy living using the exchange model and positive discipline.
• Perform data entry of client information into the database and complete other duties as assigned.

Skills & Qualifications

• Bachelor's Degree in Social Work or related field with 2 years' experience working with families experiencing trauma, mental health, substance abuse, domestic violence, homelessness, and child abuse/neglect.
• Licensed social worker preferred; valid Driver's License and dependable vehicle required; must pass CORI and SORI check within first 30 days.
• Case management experience required; experience in group facilitation a plus.
• Knowledge of the "Strengthening Families" model.
• Computer skills in Microsoft Word required.
• Bilingual preferred but not required.
• Availability for some nights and weekends on a weekly basis.

Embedded within a child welfare agency, the Case Specialist assists Case Managers with documentation, client contact, and foster parent contact processes while also performing direct social and case management services including court appearances, treatment planning, and regulatory-compliant recordkeeping. Working closely with direct supervisors, community organizations, and legal bodies, the Case Specialist ensures child safety and service continuity across assigned cases.

Primary Duties

• Assist Case Managers with essential paperwork and documentation including green card applications, funding requests, and school enrollment.
• Provide case management services including social work, counseling, treatment of clients, and coordination of community referrals.
• Ensure the child's safety while in care and attend all court hearings on assigned cases.
• Maintain collateral contact with organizations such as schools, and assist Case Managers with client and foster family contact during absences.
• Accompany youth to immigration hearings, schedule medical and dental appointments for ILP youth, and administer case notes in the UC Portal per guidelines.
• Collaborate with direct supervisor to schedule and prioritize work duties, attend required training, and stay current on all agency, federal, and state regulatory requirements.

Required Qualifications

• Bachelor's degree in Social Work or related Human Services field from an accredited college.
• Broad knowledge of basic principles, concepts, and methodology of Human Services.
• Computer and typing skills sufficient to perform essential job functions.
• Excellent verbal and written communication skills with strong critical thinking and problem-solving ability.
• Ability to provide compassionate customer service, maintain high confidentiality, meet time-sensitive deadlines, and work well under pressure.
• Active motor vehicle license with reliable vehicle and adequate insurance; must pass criminal history screen including child protection agency registries.
• Commitment to the agency's Statement of Faith, Mission Statement, and Cultural Diversity Commitment.

A key member of a team of specialists and care managers, the Case Specialist supports an assigned caseload of individuals pursuing federal disability benefits by tracking Social Security Administration application status, conducting outreach to disengaged customers, and facilitating workshops on the determination process. Collaborating across care management teams and publicly-funded program partners, the Case Specialist drives re-engagement and timely documentation submission to ensure customers successfully complete all required processes.

Accountabilities

• Work as part of a team of specialists and care managers to assist customers in successfully receiving federal disability benefits.
• Support an assigned caseload of individuals by following up on applications and reviewing status with customers regularly.
• Make regular contact with customers to review application status and gather any needed documentation for submission to the Social Security Administration.
• Provide counseling and support to ensure customers comply with requests, and conduct workshops on the application process and importance of timely response.
• Conduct outreach to disengaged customers using elevated methods including phone, letters, email, texts, and home visits to ensure re-engagement and completion of required processes.
• Track customer participation in the determination process, report accordingly, and use real-time performance feedback to improve work quality.
• Understand and follow all relevant policies, procedures, and standard forms, and use online processes to conduct and document work activities.

Experience & Qualifications

• Associate's degree or higher in social services, psychology, human services, vocational rehabilitation, or occupational rehabilitation.
• Four years of direct customer service experience in a clinical or social service environment.
• Experience in a fast-paced, performance-driven team environment; experience with publicly-funded programs, with TANF experience preferable.
• Knowledge of laws and regulatory requirements related to program responsibilities; experience assessing and accommodating customer needs.
• Training or experience in motivational interviewing techniques preferred.
• Ability to use various electronic systems to carry out duties and responsibilities.
• Exceptional customer service and engagement skills, excellent organizational skills, and strong attention to detail.

Reporting to MGA leadership, the Case Specialist builds broker relationships and delivers full Managing General Agency support from new business application processing through policy placement, managing underwriting and issuance across several lines of insurance. The work directly supports life carriers and independent brokers by ensuring new business cycles are handled accurately and efficiently, sustaining the operational pipeline that connects brokers to carrier products.

Role Responsibilities

• Provide full Managing General Agency support to brokers throughout the new business cycle up to and including policy placement and service.
• Process new business applications across several lines of insurance.
• Manage and oversee the underwriting and issue process.
• Build strong working relationships with internal and external partners including life carriers and independent brokers.
• Assist with marketing and inquiries as required.

Professional Experience

• Minimum 3 years of industry experience.
• LOMA education an asset.
• Working knowledge of MS Office, Outlook, Wealthserv, Lifeguide, and life insurance carrier product software.
• Strong interpersonal, oral, and written communication skills with a high degree of integrity and initiative.
• Ability to handle multiple and conflicting priorities and work both independently and within a team environment.
• Professional presentation.

Based within a healthcare services operation supporting the Veterans Administration, the Medical Case Specialist shapes case workflows by triaging referral downloads, verifying CPT and CLIN code assignments, and scheduling examinations to meet contract timeliness guidelines. Serving claimants, medical providers, and VA program administrators, the Medical Case Specialist ensures that consultative reports and diagnostic results are received and actioned in a manner that upholds contractual scheduling standards.

Key Deliverables

• Answer phones from automated call distribution system and triage daily referral downloads, assigning appropriate worksheets by condition as identified by the Veterans Administration.
• Verify appropriate CPT and CLIN codes are assigned to each case.
• Communicate directly with claimants and providers, obtain medical history for specific conditions, and determine appropriate examinations, tests, and specialists required.
• Schedule appointments for examinees including follow-up and rescheduled appointments, and ensure all examinees and providers receive necessary documentation.
• Confirm consultative reports and diagnostic test results are received in a timely manner and meet or exceed contract timeliness guidelines in scheduling and case management systems.
• Perform other projects and duties as assigned.

Position Requirements

• High school diploma, GED, or 2 years of relevant experience.
• 0–1 year of related experience; healthcare experience preferred.
• Knowledge of medical terminology and medical coding.
• Strong computer skills at intermediate level; experience with electronic medical scheduling and case management software.
• Proven ability to plan and organize workload, manage competing priorities, and follow through effectively.
• Flexibility to work early morning, evening, and/or weekend shifts; must successfully pass NACI background investigation.

The Case Specialist delivers multi-level case processing services within a Trial Court office, advancing through a defined series from entry-level intake duties to complex case management requiring independent judgment, and may eventually support court sessions alongside a Sessions Clerk or Assistant Clerk. Reporting to court supervisors and serving attorneys, litigants, law enforcement, and the general public, the Case Specialist enables accurate docketing, document preparation, and public-facing service that keeps court operations running in compliance with Trial Court policies.

Day-to-Day Responsibilities

• Provide customer service to attorneys, litigants, law enforcement personnel, and the general public, including assisting with forms, responding to inquiries, and handling complex or sensitive requests as experience level requires.
• Receive training and assist with MassCourts or other automated case management systems, including electronic filing, docketing, scheduling, and management reporting.
• Perform case intake duties including receiving court documents, determining case category, making docket entries, and preparing case file folders manually or through automated systems.
• Prepare and enter complaints, petitions, summonses, warrants, orders, and other standard documents; send notices to parties and attorneys.
• Answer incoming calls, route callers, take messages, perform cashiering duties, and maintain statistical data on case processing activities.
• Copy, file, retrieve, and sort court papers; process incoming and outgoing mail.
• Process complex cases involving multiple offices, agencies, parties, and legal issues; perform advanced case processing requiring independent judgment as level progresses.
• Assist in training new and existing employees; serve as a resource to staff across offices at senior levels.
• Perform administrative support responsibilities including composing correspondence, preparing reports, maintaining calendars, and arranging meetings.
• May provide assistance to a Sessions Clerk or Assistant Clerk during court sessions, including arranging documents, marking dockets, and processing files after court.

Knowledge Skills & Abilities

• High school diploma or equivalent; minimum two years of experience at each preceding level required for advancement to Case Specialist II, III, and IV.
• Some general clerical or customer service experience; demonstrated ability to process complex cases from beginning to end without close supervision at senior levels.
• General knowledge of modern office practices and procedures; working knowledge of Trial Court fiscal policies and ability to prepare fiscal reports required at senior levels.
• Demonstrated ability to identify and resolve problems with court documents within established guidelines; ability to perform routine data entry at an acceptable rate of speed.
• Ability and experience using personal computers including MS Word; MS Excel and spreadsheet experience preferred.
• Working knowledge of MassCourts or other court automated case management system, with demonstrated ability to perform complex functions such as merge letters, macros, and templates at senior levels.
• Ability to serve the public courteously and professionally, communicate effectively, and establish effective working relationships with court staff.
• Demonstrated ability to respond to unusual, complicated, or sensitive requests for information and to train employees at senior levels.

Case Specialist manages administration of FMLA standalone and other leave claims from eligibility intake through return-to-work confirmation, applying federal and state regulatory requirements and established FMLA workflow procedures to each determination. The work directly supports employees, HR teams, and GCSO operations by maintaining accurate leave system records and ensuring timely, compliant claim decisions across an extended coverage window of 8am to 11pm.

Areas of Ownership

• Handle and administer FMLA standalone and other leave claims in adherence to federal and state regulatory requirements and established FMLA workflow procedures.
• Complete eligibility decisions during intake calls and gather pertinent data from employees or supporting systems as necessary.
• Promptly review new FMLA and other leave claims, evaluate against appropriate leave plans, and make initial claim decisions.
• Perform leave follow-ups including recertification of health conditions, intermittent claim tracking, and return-to-work confirmation.
• Update systems to accurately reflect leave status and ensure appropriate diary documentation exists.
• Perform periodic visits to the assigned GCSO office as needed for team events, meetings, training, and business continuity.

Background & Experience

• High school diploma required; Bachelor's degree preferred.
• 2+ years of related experience.
• Working knowledge of FMLA, disability, and leave procedures preferred; claims experience, specifically disability, preferred.
• Knowledge of system applications preferred.
• Strong customer satisfaction focus and strong attention to detail.
• Must be available to work between the hours of 8am–11pm.