PFML- Absence Management Claims Consultant

We're actively seeking a talented PFML-Absence Management Claims Consultant to join our Workforce Benefits Division. As a PFML Absence Management Claims Consultant , you'll play a key role in building and delivering a best-in-class Paid Family and Medical Leave claims experience. This role will serve as a PFML subject matter expert and will be responsible for helping design and build the future-state PFML claims operation.

The PFML Claims Consultant will partner closely with Product, Technology, Legal, Compliance, and Operations teams to define business requirements, support system configuration and testing, develop workflows, create claims procedures and training materials, drive process improvements, and ensure regulatory requirements are effectively translated into scalable operational solutions.

This individual will help build the foundation for PFML claims administration while delivering an empathetic, compliant, and customer-centered experience for employees and employers.

The ideal candidate combines strong technical expertise, regulatory knowledge, critical thinking, and compassion while helping customers navigate important life events.

- Serve as a key business partner in the design, implementation, and ongoing enhancement of Pacific Life's Paid Family and Medical Leave (PFML) capabilities.

- Partner closely with Product Owners, Business Analysts, Technology teams, and external vendors to define business requirements, user stories, workflows, business rules, and system functionality needed to support PFML administration.

- Act as the PFML claims subject matter expert (SME) throughout the product development lifecycle, including requirements gathering, solution design, testing, implementation, and production support.

- Help design and build the end-to-end PFML claims experience, ensuring processes are scalable, compliant, efficient, and customer focused.

- Develop and maintain claims procedures, workflows, job aids, training materials, and operational documentation aligned with state regulations, product design, and system capabilities.

- Participate in system configuration reviews, user acceptance testing (UAT), workflow validation, defect identification, and implementation of new PFML products and enhancements.

- Serve as a SME and monitor evolving state PFML legislation and regulatory requirements and translate business and compliance requirements into operational processes and system functionality.

- Consult on industry best practices and recommend innovative solutions to improve the customer experience, claims outcomes, operational efficiency, and automation opportunities.

- Partner closely with Legal, Compliance, Employer Services, Customer Service, Operations, Product, and Technology teams to ensure compliant and effective administration of PFML programs.

- Administer and adjudicate Paid Family and Medical Leave (PFML) claims from intake through resolution, ensuring timely, accurate, and compliant claim decisions.

- Interpret state-specific eligibility requirements, benefit calculations, waiting periods, leave durations, and documentation requirements.

- Effectively communicate claim decisions, requirements, next steps, and benefit information to claimants, employers, brokers, and internal partners.

- Demonstrate an empathetic and customer-centric mindset while assisting employees during significant family, medical, and caregiving events.

- Identify opportunities to improve customer experience, operational efficiency, quality, and compliance within the claims organization.

- Assist with onboarding, training, mentoring, and development of team members.

- Participate in audits, quality reviews, special projects, process reviews, and departmental initiatives.

- Support and promote change management, innovation, and continuous improvement initiatives.

- Demonstrate sound judgment and discretion regarding confidential and sensitive information.

- 5+ years of experience in Paid Family and Medical Leave (PFML), disability claims, leave management, absence management, insurance claims, or a related field.

- Strong knowledge of state PFML programs, leave laws, regulatory requirements, and employer-sponsored leave and disability products.

- Experience interpreting statutes, regulations, policy provisions, administrative guidelines, and complex business requirements.

- Demonstrated ability to make fair, balanced, and objective decisions with a high degree of integrity and professionalism.

- Strong analytical, investigative, problem-solving, and critical-thinking skills.

- Excellent verbal and written communication skills, with the ability to effectively communicate with customers, employers, brokers, and internal partners.

- Customer-focused with a compassionate and empathetic approach to helping employees navigate significant life events.

- Strong organizational and time-management skills with the ability to manage multiple priorities in a fast-paced environment.

- Ability to work independently while collaborating effectively with cross-functional teams, including Product, Technology, Legal, Compliance, Operations, and Customer Service.

- Experience supporting process improvement initiatives, workflow design, procedure development, training, quality assurance, testing, or system implementation activities.

- Detail-oriented with the ability to learn and become proficient in claims administration systems, workflow tools, reporting platforms, and related technologies.

- Insurance designations, industry certifications, and experience with FMLA, ADA, Disability, or integrated absence management programs are preferred.