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 Clinical Specialist, your primary purpose will be to perform standard clinical evaluations on claims that require additional review based on medical condition, client requirement, and/or complexity. You will consult with providers and employees by providing case direction and ensure medical information substantiates the need for employee absence from work.
Responsibilities:
- Perform standard clinical reviews of referred medical claims based on client requirements to ensure accurate and sufficient information is received by employees and providers to support the claim request and document decision rationale.
- Complete medical review of all claims by reviewing medical documentation received and applying practical clinical knowledge to ensure information substantiates disability and to interpret the impact the condition has on the ability to perform job functions.
- Communicate clearly and professionally, on the phone and/or in writing with employee and/or providers to discuss employee's clinical status, progress, and work status.
- Provide clear and appropriate follow-up recommendations for ongoing medical management of claims; ensure appropriate recommendations are made on claims.
- Consistently achieve appropriate quality audit scores.
- Act as clinical resource to claims examiners to provide guidance on the medical management of claims including comprehension of medical terminology and substantiating claim decisions.
Additional Responsibilities:
- Act as a backup for key disability claims on an ad hoc basis.
- Perform other duties as assigned.
- Travel as required.
Qualifications:
- Bachelor's degree or equivalent preferred.
- Current RN, LVN, LPN, CRC, COHN CVE, LPC and/or LCSW Licenses required.
- Four (4) years of related experience or equivalent combination of experience and education required, including experience in a direct medical/psychological setting or physical industrial medicine and previous insurance or related experience.
Skills & Knowledge:
- Knowledge of current medical practices in health care management in a variety of areas.
- Excellent oral and written communication, including presentation skills.
- Proficient computer skills including working knowledge of Microsoft Office.
- Analytical and interpretive skills.
- Strong organisational and multitasking skills.
- Excellent interpersonal skills.
- Ability to exercise judgement and critical thinking skills.
- Ability to work in a team environment.
Work Environment:
- Ability to sit at a desk for extended periods while operating a computer and phone system.
- Travel as required.