Sedgwick
Overview
Base pay range: $22.30/hr - $23.00/hr 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. Salary information reflects the jurisdiction noted in this job posting. Actual compensation is influenced by factors including but not limited to skill set, experience, and location. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
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 and arranges appropriate referral of claims to outside vendors.
ESSENTIAL FUNCTIONS And RESPONSIBILITIES Makes independent claim determinations, based on 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 (e.g., attending physician statements, office notes, operative reports) 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 typical guidelines.
Utilizes appropriate clinical resources in case assessment (e.g., duration guidelines, in-house clinicians) as needed.
Determines benefits due pursuant to a disability plan, makes timely payments/approvals and adjustments for workers’ compensation, SSDI, and other disability offsets.
Informs claimants of required documentation, time frames, payment information, and claims status by phone, written correspondence, and/or claims system.
Communicates with claimants’ providers to set expectations regarding return to work.
Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
Communicates clearly and timely with claimants and clients on all aspects of the claims process by phone, written correspondence, and/or claims system.
Coordinates investigative efforts to ensure appropriateness; provides thorough review of contested claims.
Evaluates and arranges appropriate referrals of claims to outside vendors or physician advisor reviews, surveillance, IMEs, FCEs, 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(s) minimum requirements.
ADDITIONAL FUNCTIONS And RESPONSIBILITIES Performs other duties as assigned.
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, required offsets and deductions, disability duration and medical management practices and Social Security 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 working knowledge of 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 program
Effective decision-making and negotiation skills
Ability to exercise judgement autonomously within established procedures
Work Environment
When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines.
Physical: Ability to sit at a desk for extended periods while operating a computer and phone system. Travel as required.
Auditory/Visual: Hearing, vision and talking.
Equal Opportunity
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
Application Note
If you&aposre excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying anyway. Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience.
#J-18808-Ljbffr
Base pay range: $22.30/hr - $23.00/hr 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. Salary information reflects the jurisdiction noted in this job posting. Actual compensation is influenced by factors including but not limited to skill set, experience, and location. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
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 and arranges appropriate referral of claims to outside vendors.
ESSENTIAL FUNCTIONS And RESPONSIBILITIES Makes independent claim determinations, based on 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 (e.g., attending physician statements, office notes, operative reports) 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 typical guidelines.
Utilizes appropriate clinical resources in case assessment (e.g., duration guidelines, in-house clinicians) as needed.
Determines benefits due pursuant to a disability plan, makes timely payments/approvals and adjustments for workers’ compensation, SSDI, and other disability offsets.
Informs claimants of required documentation, time frames, payment information, and claims status by phone, written correspondence, and/or claims system.
Communicates with claimants’ providers to set expectations regarding return to work.
Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
Communicates clearly and timely with claimants and clients on all aspects of the claims process by phone, written correspondence, and/or claims system.
Coordinates investigative efforts to ensure appropriateness; provides thorough review of contested claims.
Evaluates and arranges appropriate referrals of claims to outside vendors or physician advisor reviews, surveillance, IMEs, FCEs, 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(s) minimum requirements.
ADDITIONAL FUNCTIONS And RESPONSIBILITIES Performs other duties as assigned.
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, required offsets and deductions, disability duration and medical management practices and Social Security 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 working knowledge of 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 program
Effective decision-making and negotiation skills
Ability to exercise judgement autonomously within established procedures
Work Environment
When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines.
Physical: Ability to sit at a desk for extended periods while operating a computer and phone system. Travel as required.
Auditory/Visual: Hearing, vision and talking.
Equal Opportunity
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
Application Note
If you&aposre excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying anyway. Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience.
#J-18808-Ljbffr