Description
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.
As a Disability Representative Sr, your primary purpose will be to provide disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation. This includes determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims including comorbidities, concurrent plans, and complex ADA accommodations; 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.
Key responsibilities:
- Make independent claim determinations, based on the information received, to approve complex disability claims or make recommendations to team lead to deny claims based on the disability plan.
- Review and analyze complex medical information to determine if the claimant is disabled as defined by the disability plan.
- Oversee additional facets of complex claims including comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
- Utilize clinical resources in case assessment as needed.
- Determine benefits due pursuant to a disability plan, make timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
- Inform claimants of documentation required to process claims, required time frames, payment information and claims status.
- Communicate with claimants' providers to set expectations regarding return to work.
- Medically manage complex disability claims ensuring compliance with duration control guidelines and plan provisions.
- Coordinate investigative efforts and provide thorough review of contested claims.
- Evaluate and arrange appropriate referral of claims to outside vendors or physician advisor reviews.
- Negotiate return to work with or without job accommodations.
- Refer cases to team lead and clinical case management for additional review when appropriate.
- Maintain professional client relationships and provide excellent customer service.
Requirements:
- High school diploma or GED required; bachelor's degree from an accredited university or college preferred.
- Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.
- 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.
- Effective decision-making and negotiation skills.
- Ability to exercise judgement autonomously within established procedures.