Advocacy Coordination Team Specialist

Primary Purpose Actively researches, resolves, and administers escalated inquiries for all lines of business, including but not limited to Family Medical Leave (FMLA), complex paid and unpaid state, military, and company‑specific leaves, accommodations, disability and statutory claims. Provides excellent customer service displaying care and empathy to callers regarding claims and executes technical and jurisdictional requirements for accurate claims processing, benefit review and interpretation of regulations, financial payment processing, and error correction of complex or high exposure claims. Essential Functions and Responsibilities Makes independent claim determinations, based on the information received, to approve complex claims or make a recommendation to team lead to deny claims based on the requirements. Analyzes and authorizes leave, accommodation, disability, and statutory claims and determines benefits due pursuant to client plans, and state and federal regulations. Enters and adjusts payments and evaluates file interface to support payment research and resolution. Communicates clearly and professionally with claimant and client on all aspects of the claims process including claim approval, decision authority level to move the call forward, and issue resolution by phone, written correspondence and/or claims system. Facilitates claim resolution and handles escalated calls with claimant, human resources managers, treating physician’s office, client, or others with a goal of one‑call resolution. Ensures claims files are coded correctly and that adequate documentation is in the claim. Reviews and analyzes complex medical information (i.e. diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan and takes all necessary action to manage claims process to completion. Informs claimants and client of documentation required to process claims, required timeframes, payment information and claims status. Determines benefits due, makes timely and accurate claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets. Maintains professional client relationships and adheres to client specific requirements such as service level expectations, regulatory requirements, and reporting. Meets the organization’s quality program(s) minimum requirements. Additional Functions and Responsibilities Performs other duties as assigned. Qualifications Education & Licensing High school diploma or GED required. Bachelor’s degree from an accredited college or university preferred. Experience Three (3) years of related experience or equivalent combination of experience and education required to include two (2) years of disability claims experience. Experience with SMART, SIR, GAIN, or other HR systems preferred. Experience with TAMS, Juris, viaOne express, and mySedgwick preferred for internal candidates. Skills & Knowledge Knowledge of ERISA regulations, state and federal FMLA, ADAAA, Social Security application procedures, required offsets and deductions, and disability procedures Working knowledge of medical terminology and duration management Proficient computer skills including working knowledge of Microsoft Office Exemplary call handling and de‑escalation skills Excellent interpersonal communication skills, oral and written Analytical, interpretive, and critical thinking skills Effective decision‑making Ability to manage ambiguity Strong organizational and multitasking skills Ability to exercise judgement autonomously within established procedures Ability to work in a team environment Ability to meet or exceed performance competencies as required by program Work Environment Required to adhere to a set schedule with established break times. 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; ability to handle multiple priorities simultaneously; and ability to meet 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. Note Credit security clearance, confirmed via a background credit check, is required for this position. Compensation and Benefits 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 - $24.00. 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. Legal Statements Sedgwick is an Equal Opportunity Employer and a Drug‑Free Workplace. Application Encouragement 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. #J-18808-Ljbffr