Sedgwick
By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.
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Disability Representative Sr.
Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence: Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063 Dubuque, IA : 4141 Westmark Drive, Dubuque, IA 52002 Cedar Rapids, IA : 333 1st Street SE Ste. 200 Cedar Rapids IA 52401 Coralville, IA : 3273 Ridgeway Drive Coralville IA 52241 Dublin, OH : 5500 Glendon Court Dublin OH 43016 Memphis, TN : 8125 Sedgwick Way, Memphis TN 38125 New Albany, OH : 7795 Walton Parkway New Albany, OH 43054 Indianapolis, IN : 8909 Purdue Road Suite 501 Indianapolis, IN 46268 Southfield, MI : 300 Galleria Officentre Southfield MI 48034 Orlando, FL : 12650 Ingenuity Dr Orlando FL 32826 Primary Purpose
To provide disability case management and claim determinations based on complex medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims; coordinating investigative efforts, thoroughly reviewing contested claims, negotiating return to work with or without job accommodations, and evaluating and arranging appropriate referral of claims to outside vendors. Essential Functions and Responsibilities
Analyze, approve, and authorize assigned claims and determine benefits due pursuant to a disability plan. Review and analyze complex medical information (e.g., diagnostic tests, office notes, operative reports) to determine if the claimant is disabled as defined by the disability plan. Utilize appropriate clinical resources in case assessment (e.g., duration guidelines, in-house clinicians). Communicate with the claimants' providers to set expectations regarding return to work. Determine benefits due, make timely claims payments/approvals and adjustments for workers' compensation, Social Security Disability Income (SSDI), and other disability offsets. Medically manage disability claims ensuring compliance with duration control guidelines and plan provisions. Communicate clearly with claimants and clients on all aspects of the claims process via phone and/or written correspondence. Inform claimants of documentation required to process claims, time frames, payment information, and claims status. Coordinate investigative efforts ensuring appropriateness; review contested claims thoroughly. Evaluate and arrange appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and related activities. Negotiate return to work with or without job accommodations via the claimant's physician and employer. Refer cases as appropriate to team lead and clinical case management. Maintain professional client relationships. Additional Functions and Responsibilities
Perform other duties as assigned. Support the organization's quality programs. Qualifications
Education & Licensing
Bachelor's degree from an accredited university or college preferred. Experience
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience required. Skills & Knowledge
Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices, and Social Security application procedures. Working knowledge of medical terminology and duration management. Excellent oral and written communication, including presentation skills. Proficiency in Microsoft Office products. Analytical and interpretive skills. Strong organizational skills. Ability to work in a team environment. Excellent negotiation skills. Ability to meet or exceed performance competencies. Work Environment
When applicable and appropriate, consideration will be given to reasonable accommodations. Physical and Cognitive Requirements:
Clear thinking, good judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress and multiple priorities; meet deadlines; physical ability to keyboard and travel as required; hearing, vision, talking. Note:
Credit security clearance, confirmed via a background credit check, is required for this position. The statements in this document describe the general nature and level of work performed by a colleague in this role. They are not a comprehensive list of functions, duties, or variances. Management may modify duties at any time.
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Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence: Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063 Dubuque, IA : 4141 Westmark Drive, Dubuque, IA 52002 Cedar Rapids, IA : 333 1st Street SE Ste. 200 Cedar Rapids IA 52401 Coralville, IA : 3273 Ridgeway Drive Coralville IA 52241 Dublin, OH : 5500 Glendon Court Dublin OH 43016 Memphis, TN : 8125 Sedgwick Way, Memphis TN 38125 New Albany, OH : 7795 Walton Parkway New Albany, OH 43054 Indianapolis, IN : 8909 Purdue Road Suite 501 Indianapolis, IN 46268 Southfield, MI : 300 Galleria Officentre Southfield MI 48034 Orlando, FL : 12650 Ingenuity Dr Orlando FL 32826 Primary Purpose
To provide disability case management and claim determinations based on complex medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims; coordinating investigative efforts, thoroughly reviewing contested claims, negotiating return to work with or without job accommodations, and evaluating and arranging appropriate referral of claims to outside vendors. Essential Functions and Responsibilities
Analyze, approve, and authorize assigned claims and determine benefits due pursuant to a disability plan. Review and analyze complex medical information (e.g., diagnostic tests, office notes, operative reports) to determine if the claimant is disabled as defined by the disability plan. Utilize appropriate clinical resources in case assessment (e.g., duration guidelines, in-house clinicians). Communicate with the claimants' providers to set expectations regarding return to work. Determine benefits due, make timely claims payments/approvals and adjustments for workers' compensation, Social Security Disability Income (SSDI), and other disability offsets. Medically manage disability claims ensuring compliance with duration control guidelines and plan provisions. Communicate clearly with claimants and clients on all aspects of the claims process via phone and/or written correspondence. Inform claimants of documentation required to process claims, time frames, payment information, and claims status. Coordinate investigative efforts ensuring appropriateness; review contested claims thoroughly. Evaluate and arrange appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and related activities. Negotiate return to work with or without job accommodations via the claimant's physician and employer. Refer cases as appropriate to team lead and clinical case management. Maintain professional client relationships. Additional Functions and Responsibilities
Perform other duties as assigned. Support the organization's quality programs. Qualifications
Education & Licensing
Bachelor's degree from an accredited university or college preferred. Experience
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience required. Skills & Knowledge
Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices, and Social Security application procedures. Working knowledge of medical terminology and duration management. Excellent oral and written communication, including presentation skills. Proficiency in Microsoft Office products. Analytical and interpretive skills. Strong organizational skills. Ability to work in a team environment. Excellent negotiation skills. Ability to meet or exceed performance competencies. Work Environment
When applicable and appropriate, consideration will be given to reasonable accommodations. Physical and Cognitive Requirements:
Clear thinking, good judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress and multiple priorities; meet deadlines; physical ability to keyboard and travel as required; hearing, vision, talking. Note:
Credit security clearance, confirmed via a background credit check, is required for this position. The statements in this document describe the general nature and level of work performed by a colleague in this role. They are not a comprehensive list of functions, duties, or variances. Management may modify duties at any time.
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