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.
As a Disability Representative Sr, you will provide disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation.
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, complex ADA accommodations, and claims outside of typical guidelines.
- Utilizes the appropriate clinical resources in case assessment as needed.
- Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
- Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system.
- Communicates with the claimants' providers to set expectations regarding return to work.
- Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
- Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
- Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or 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.
Qualifications:
- 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.
- 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.
- 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.