Sedgwick
Disability Representative Sr – Sedgwick
Primary purpose: Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation, including determining benefits due and making timely payments/approvals and adjustments. Medically manages disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, reviews contested claims, negotiates return to work with or without job accommodations, and evaluates/refers cases to outside vendors when appropriate. Responsibilities
Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan. Reviews and analyzes complex medical information to determine if the claimant is disabled as defined by the disability plan. Oversees additional facets of complex claims including comorbidities, concurrent plans, ADA accommodations, and claims outside of typical guidelines. Utilizes appropriate clinical resources in case assessment as needed. Determines benefits due pursuant to a disability plan, and makes timely payments/approvals and adjustments for workers compensation, SSDI, and other offsets. Informs claimants of documentation required, time frames, payment information, and claims status by phone, written correspondence, or claims system. Communicates with claimants’ providers to set expectations regarding return to work. Medically manages complex disability claims ensuring compliance with duration guidelines and plan provisions. Communicates clearly and timely with claimants and clients on all aspects of the claims process. Coordinates investigative efforts and provides thorough review of contested claims. Evaluates and arranges referrals to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and related disability activities. Negotiates return to work with or without job accommodations via the claimant’s physician and employer. Refers cases to team lead and clinical case management for additional review when appropriate. Maintains professional client relationships and provides excellent customer service. Meets the organization’s quality program minimum requirements. Qualifications
Education & Licensing
High School diploma or GED required. Bachelor's degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations. Experience
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred. Skills & Knowledge
Knowledge of ERISA regulations, offsets and deductions, disability duration and medical management practices and SSDI application procedures Knowledge of state and federal FMLA regulations Working knowledge of medical terminology and duration management Excellent oral and written communication, including presentation skills Proficient computer skills including Microsoft Office Analytical, interpretive, and critical thinking skills Ability to manage ambiguity Strong organizational and multitasking skills Ability to work in a team environment Ability to meet or exceed performance competencies as required by the program Effective decision-making and negotiation skills Ability to exercise judgment autonomously within established procedures Work Environment
When applicable and appropriate, consideration will be given to reasonable accommodations. Compensation and Benefits
The posting notes compensation for the jurisdiction with a starting pay range of $23.32 - $25.00. A comprehensive benefits package is offered including medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other voluntary benefits. Equal Opportunity
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable fair chance laws and ordinances. Sedgwick is building a diverse, equitable, and inclusive workplace and welcomes candidates with a unique combination of skills and experience.
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Primary purpose: Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation, including determining benefits due and making timely payments/approvals and adjustments. Medically manages disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, reviews contested claims, negotiates return to work with or without job accommodations, and evaluates/refers cases to outside vendors when appropriate. Responsibilities
Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan. Reviews and analyzes complex medical information to determine if the claimant is disabled as defined by the disability plan. Oversees additional facets of complex claims including comorbidities, concurrent plans, ADA accommodations, and claims outside of typical guidelines. Utilizes appropriate clinical resources in case assessment as needed. Determines benefits due pursuant to a disability plan, and makes timely payments/approvals and adjustments for workers compensation, SSDI, and other offsets. Informs claimants of documentation required, time frames, payment information, and claims status by phone, written correspondence, or claims system. Communicates with claimants’ providers to set expectations regarding return to work. Medically manages complex disability claims ensuring compliance with duration guidelines and plan provisions. Communicates clearly and timely with claimants and clients on all aspects of the claims process. Coordinates investigative efforts and provides thorough review of contested claims. Evaluates and arranges referrals to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and related disability activities. Negotiates return to work with or without job accommodations via the claimant’s physician and employer. Refers cases to team lead and clinical case management for additional review when appropriate. Maintains professional client relationships and provides excellent customer service. Meets the organization’s quality program minimum requirements. Qualifications
Education & Licensing
High School diploma or GED required. Bachelor's degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations. Experience
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred. Skills & Knowledge
Knowledge of ERISA regulations, offsets and deductions, disability duration and medical management practices and SSDI application procedures Knowledge of state and federal FMLA regulations Working knowledge of medical terminology and duration management Excellent oral and written communication, including presentation skills Proficient computer skills including Microsoft Office Analytical, interpretive, and critical thinking skills Ability to manage ambiguity Strong organizational and multitasking skills Ability to work in a team environment Ability to meet or exceed performance competencies as required by the program Effective decision-making and negotiation skills Ability to exercise judgment autonomously within established procedures Work Environment
When applicable and appropriate, consideration will be given to reasonable accommodations. Compensation and Benefits
The posting notes compensation for the jurisdiction with a starting pay range of $23.32 - $25.00. A comprehensive benefits package is offered including medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other voluntary benefits. Equal Opportunity
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable fair chance laws and ordinances. Sedgwick is building a diverse, equitable, and inclusive workplace and welcomes candidates with a unique combination of skills and experience.
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