Disability Claims Specialist — Complex Case Management

Sedgwick Claims Management Services Ltd; Dubuque (IA); On-site; USD 70,000 - 110,000; Full time

Job summary

Sedgwick Claims Management Services Ltd in the United States is hiring a Senior Disability Representative to assess complex disability claims and determine benefits under applicable plans, based on medical documentation and plan interpretation. You will coordinate payments, approvals and adjustments, and work with involved providers and claimants.

The role requires independent decision-making, strong medical knowledge, ERISA awareness, and the ability to negotiate return-to-work accommodations.

Qualifications

• Proficiency in ERISA regulations and disability plan provisions.
• Knowledge of FMLA regulations and disability duration management.
• Ability to interpret medical documentation and make informed disability determinations.
• Excellent written and oral communication, including documentation and client updates.

Responsibilities

• Makes independent claim determinations to approve complex disability claims or deny per plan.
• Reviews complex medical information to determine disability status.
• Oversees comorbidities, concurrent plans, and ADA accommodations for complex claims.
• Determines benefits due and ensures timely payments/adjustments.
• Negotiates return to work with providers and employers.
• Communicates with claimants and providers regarding process and status.
• Refers cases for outside reviews or further evaluation when needed.
• Maintains client relationships and supports quality programs.

Skills

ERISA knowledge

FMLA knowledge

Medical terminology

Communication skills

Microsoft Office

Analytical thinking

Negotiation skills

Decision making

Education

High School diploma or GED

Bachelor's degree preferred

Tools

Microsoft Office

Job description

Sedgwick Claims Management Services Ltd in the United States is hiring a Senior Disability Representative to assess complex disability claims and determine benefits under applicable plans, based on medical documentation and plan interpretation. You will coordinate payments, approvals and adjustments, and work with involved providers and claimants.

The role requires independent decision-making, strong medical knowledge, ERISA awareness, and the ability to negotiate return-to-work accommodations.