State of Maryland

The Claims and Benefits Specialist V is the technical expert responsible for conducting complex program integrity research and formulating strategic policy recommendations for claims in accordance with program policies and State regulations in the Division of Family and Medical Leave Insurance, Maryland Department of Labor. Employees in this classification function as the technical Subject Matter Expert (SME), providing authoritative advice, guidance, and consultation on the most complex, specialized, or sensitive matters. Positions at this level serve as an agency or statewide expert resource, resolve high-level complex operational or regulatory issues, and may contribute to policy development and operational strategy, operating under general direction.

Employees in this classification receive general supervision from a FAMLI Claims & Benefits Supervisor, FAMLI Claims & Benefits Manager, or other designated program administrator.

Position placement in this classification is determined by the Classification Job Evaluation Methodology. The use of this method involves comparing the assigned duties and responsibilities of a position to the job criteria found in the Nature of Work and Examples of Work sections of a classification specification.

The Claims & Benefits Specialist V is differentiated from the Claims & Benefits Specialist IV in that the Claims & Benefits Specialist IV assigns, reviews, and approves the work of and trains lower-level Claims & Benefits Specialists, or resolves escalated, high-level claims and reconsiderations. The Claims & Benefits Specialist V is differentiated from the Claims & Benefits Specialist Supervisor in that the Claims & Benefits Specialist Supervisor has supervisory responsibility for lower-level Claims & Benefits Specialists.

Evaluates medical reconsiderations by synthesizing current and supplemental evidence to re-adjudicate previously rejected claims, ensuring appropriate benefit issuance or confirmation of denial;

Maintains accountability for the adjudication of potentially disqualifying factors identified throughout the claims lifecycle;

Compiles comprehensive appeal documentation and represents the FAMLI Claims and Benefits division at formal appeal hearings, including providing expert testimony regarding review determinations;

Administers overpayment and underpayment protocols, oversees recoupment efforts, and performs rigorous validation of benefit data to ensure institutional standards for timeliness and precision are met;

Conducts program integrity research to identify data trends and systemic disparities, referring suspicious or questionable claims to the specialized program integrity unit for further investigation;

Directs and manages complex benefit issuance processes through detailed research and oversight;

Translates data analysis into actionable reports and strategic recommendations for executive management consideration;

Evaluates operational procedures to identify areas for process improvement, escalates critical issues to agency leadership, and contributes to the modification of program goals;

Monitors claims activities to detect fraudulent behavior or improper payments, validating the accuracy of claim and benefit data through continuous evaluation;

Functions as the technical Subject Matter Expert (SME) regarding all facets of Claims and Benefits operations;

Resolves inquiries, complaints, and comments that the Customer Care team cannot resolve, troubleshooting common issues and acting as a point of escalation;

Reviews accuracy of and resolves issues with claims and/or benefit issuance;

Analyzes claims to recommend eligibility using knowledge or program policies, procedures, and regulations;

Researches and gathers information for outstanding issues on claims and/or benefits issuance;

Conducts fact-finding interviews with claimants and other stakeholders;

Identifies potentially disqualifying issues in claimants’ benefits eligibility;

Addresses and researches customer concerns involving claims and benefits escalated from the Customer Care team;

May perform claims intake and processing;

May assist the Customer Care team by answering phone calls, emails, and/or chats from claimants and employers;

Performs other related duties.

Knowledge of State family and medical leave laws, rules, and regulations;

Skill in communicating effectively with a diverse range of clients both verbally and in writing;

Skill in the use of standard office equipment, such as photocopiers, calculators, personal computers, and printers;

Ability to exercise sound and impartial judgment in analyzing facts and evidence, evaluating such information, and drawing valid conclusions from documentary evidence in making sound decisions;

Ability to establish and maintain effective and harmonious working relationships with the general public, employers, healthcare professionals, and co-workers;

Ability to organize daily work plans;

Ability to learn and apply new computer applications and computer systems;

Ability to apply State family and medical leave laws, rules, and regulations and make appropriate recommendations;

Ability to handle complex claims;

Ability to provide technical guidance and direction to lower-level Claims & Benefits Specialists;

Ability to work independently and as part of a team.

Education: Graduation from a high school or possession of a high school equivalency certificate.

Experience: Seven (7) years of experience in public contact, including explaining information, gathering and compiling data, performing analysis of data, or completing general administrative tasks.

Notes:

1. Candidates may substitute the possession of a Bachelor's degree from an accredited four-year college or university for four (4) years of required experience.

2. Candidates may substitute additional college education at an accredited college or university at the rate of thirty (30) credit hours for one (1) year of the required experience.

Class specifications are broad descriptions covering groups of positions used by various State departments and agencies. Position descriptions maintained by the using department or agency specifically address the essential job functions of each position.

This is a Skilled Service classification in the State Personnel Management System. All positions in this classification are Skilled Service positions. Some positions in Skilled Service classifications may be designated Special Appointment in accordance with the State Personnel and Pensions Article, Section 6-405, Annotated Code of Maryland.

This classification is assigned to Bargaining Unit G, Engineering, Scientific, and Administrative Professionals classes. As provided by the State Personnel and Pensions Article, Section 3-102, special appointment, temporary, contractual, managerial, and confidential employees are excluded from collective bargaining. Additionally, certain executive branch agencies are exempt from collective bargaining, and all positions in those agencies are excluded from collective bargaining.