Sedgwick
Primary Purpose
Provide 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 manage disability claims with comorbidities, concurrent plans, and complex ADA accommodations; coordinate investigative efforts, review contested claims, negotiate return-to-work, evaluate and arrange referrals to outside vendors.
Essential Functions and Responsibilities
Makes independent claim determinations to approve complex disability claims or recommend denials based on the disability plan.
Reviews and analyzes complex medical information to determine if the claimant is disabled per the plan.
Oversees additional facets of complex claims including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines.
Utilizes appropriate clinical resources in case assessment as needed.
Determines benefits due, makes timely claims payments or adjustments for workers compensation, SSDI, and other disability offsets.
Informs claimants of required documentation, time frames, payment info, and claim status by phone, written correspondence, or claims system.
Communicates with providers to set return-to-work expectations.
Medically manages claims ensuring compliance with duration guidelines and plan provisions.
Coordinates investigative efforts and reviews contested claims thoroughly.
Arranges referrals to outside vendors or physician advisor reviews, functional assessments, or related disability activities.
Negotiates return to work with or without 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.
Additional Functions and Responsibilities
Performs other duties as assigned.
Qualifications Education & Licensing
High School diploma or GED required. Bachelor's degree preferred. State certification or licensing in statutory leaves preferred or may be required based on state regulations.
Experience
Three (3) years of benefits or disability case/claims management experience or an 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 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.
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.
Mental:
Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress, multiple priorities, and 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.
The statements contained in this document are intended to describe the general nature and level of work performed by a colleague assigned to this description. They are not intended to be a comprehensive list of duties or local variances. Management retains the discretion to add or change duties of the position at any time.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
If you're excited about this role but your experience doesn't align perfectly with every qualification, consider applying anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes each person’s unique combination of skills, knowledge, and experience. You may be the right candidate for this or other roles.
Seniority Level Mid-Senior level
Employment Type Full-time
Job Function Other
Industries Insurance
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Essential Functions and Responsibilities
Makes independent claim determinations to approve complex disability claims or recommend denials based on the disability plan.
Reviews and analyzes complex medical information to determine if the claimant is disabled per the plan.
Oversees additional facets of complex claims including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines.
Utilizes appropriate clinical resources in case assessment as needed.
Determines benefits due, makes timely claims payments or adjustments for workers compensation, SSDI, and other disability offsets.
Informs claimants of required documentation, time frames, payment info, and claim status by phone, written correspondence, or claims system.
Communicates with providers to set return-to-work expectations.
Medically manages claims ensuring compliance with duration guidelines and plan provisions.
Coordinates investigative efforts and reviews contested claims thoroughly.
Arranges referrals to outside vendors or physician advisor reviews, functional assessments, or related disability activities.
Negotiates return to work with or without 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.
Additional Functions and Responsibilities
Performs other duties as assigned.
Qualifications Education & Licensing
High School diploma or GED required. Bachelor's degree preferred. State certification or licensing in statutory leaves preferred or may be required based on state regulations.
Experience
Three (3) years of benefits or disability case/claims management experience or an 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 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.
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.
Mental:
Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress, multiple priorities, and 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.
The statements contained in this document are intended to describe the general nature and level of work performed by a colleague assigned to this description. They are not intended to be a comprehensive list of duties or local variances. Management retains the discretion to add or change duties of the position at any time.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
If you're excited about this role but your experience doesn't align perfectly with every qualification, consider applying anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes each person’s unique combination of skills, knowledge, and experience. You may be the right candidate for this or other roles.
Seniority Level Mid-Senior level
Employment Type Full-time
Job Function Other
Industries Insurance
#J-18808-Ljbffr