Disability Claims Clinical Expert

Sedgwick Claims Management Services Ltd; United States; Remote; USD 62.000 - 63.000; Vollzeit

Benefits dieser Stelle

Medical insurance

Dental insurance

Vision insurance

401k

Zusammenfassung

Sedgwick is hiring a Clinical Specialist to perform standard clinical evaluations on complex medical claims and to consult with providers and employees to ensure medical information substantiates the need for employee absence from work.

The role requires a Bachelor’s degree and active licensure (RN, CRC, LPC, and/or LCSW), with at least four years of related clinical experience. Strong communication and analytical skills are essential.

Qualifikationen

• Education & Licensing: Bachelor's degree or equivalent preferred.
• Current RN, CRC, LPC and/or LCSW Licenses required.
• Current license, registration and/or professional designations as required within the jurisdiction.
• CEUs must be maintained to retain licenses/designations.
• Experience: Four (4) years in a direct medical/psychological setting or physical industrial medicine; insurance/related experience helpful.

Aufgaben

• Performs 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 documents decision rationale.
• Completes medical review of all claims by reviewing medical documentation and applying clinical knowledge to ensure information substantiates disability and interprets impact on job functions.
• Communicates clearly with employees and providers by phone or written correspondence regarding clinical status, progress, and work status.
• Provides clear follow-up recommendations for ongoing medical management of claims and ensures responses are appropriate.
• Maintains high-quality audit scores and acts as a clinical resource to claims examiners for medical terminology and substantiating claim decisions.
• Acts as a backup for key disability claims on an ad hoc basis; performs other duties as assigned; travels as required.

Kenntnisse

Clinical evaluation

Medical terminology

Communication

Teamwork

Analytical skills

Microsoft Office

Ausbildung

Bachelor's degree

RN/CRC/LPC/LCSW licenses

Jobbeschreibung

Sedgwick is hiring a Clinical Specialist to perform standard clinical evaluations on complex medical claims and to consult with providers and employees to ensure medical information substantiates the need for employee absence from work.

The role requires a Bachelor’s degree and active licensure (RN, CRC, LPC, and/or LCSW), with at least four years of related clinical experience. Strong communication and analytical skills are essential.