Disability Representative Sr

Disability Representative Sr

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.

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 managing disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, thoroughly 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 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 (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
• Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), 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.
• Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and / or claims system.
• 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.

Additional Functions and Responsibilities :

Qualifications :

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Work Environment :

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $22.30 - $23.00. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

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 in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.