Disability Clinical Specialist

Sedgwick; Miami (FL); Remote; USD 90,000 - 115,000; Full time

Job summary

Sedgwick is seeking a qualified Clinical Reviewer with licensure in nursing or related field to perform standard clinical evaluations on disability claims. You will review medical documentation, determine the need for employee absence, and guide claim decisions with clinical rationale.

In this remote/full-time role based in Florida, you will collaborate with providers and claims examiners, maintain high-quality audit scores, and support ongoing medical management of claims while providing clear

Qualifications

• Bachelor's degree or equivalent preferred.
• 4 years of related experience in a medical/psychological setting or industrial medicine.
• Insurance or related experience is preferred.

Responsibilities

• Perform standard clinical reviews of referred medical claims to gather sufficient information.
• Review medical documentation to support disability determinations.
• Communicate with employees and providers about clinical status and work status.
• Provide follow-up recommendations for ongoing medical management.
• Maintain quality audit scores.
• Act as clinical resource to claims examiners for medical guidance.

Skills

Medical/clinical knowledge

Communication skills

Analytical skills

Organizational skills

Interpersonal skills

Judgment and critical thinking

Team player

Performance competencies

Microsoft Office proficiency

Education

Bachelor's degree or equivalent preferred

Required licenses: RN/LVN/LPN/CRC/COHN CVE/LPC/LCSW

Tools

Microsoft Office

Job description

Telecommuter IA

Telecommuter MI

Telecommuter FL

Telecommuter TX

Telecommuter IN

Telecommuter TN

Full time

R78886

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.

Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies

Certified as a Great Place to Work®

Fortune Best Workplaces in Financial Services & Insurance

PRIMARY PURPOSE

Performs standard clinical evaluations on claims that require additional review based on medical condition, client requirement, and/or complexity. Consults with providers and employees by providing case direction and ensures medical information substantiates the need for employee absence from work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• 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 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.

• Communicates 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.

• Provides clear and appropriate follow-up recommendations for ongoing medical management of claims; ensures appropriate recommendations are made on claims.

• Consistently achieves appropriate quality audit scores.

• Acts 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 FUNCTIONS and RESPONSIBILITIES

• Acts as a backup for key disability claims on an ad hoc basis.

• Performs other duties as assigned.

• Travels as required.

QUALIFICATIONS

Education & Licensing

Bachelor's degree or equivalent preferred. Current RN, LVN, LPN, CRC, COHN CVE, LPC and/or LCSW Licenses required. Current license, registration and/or professional designations as required within the jurisdiction. Clinical expertise must be kept current by acquisition of the necessary CEUs to maintain licenses and designations.

Experience

Four (4) years of related experience or equivalent combination of experience and education required to include 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 (including, but not limited to, orthopedics, general medicine for acute and chronic conditions, general surgery, mental health, obstetrics, oncology, and physical and occupational rehabilitation)

• Excellent oral and written communication, including presentation skills

• Proficient computer skills including working knowledge of Microsoft Office

• Analytical and interpretive skills

• Strong organizational and multitasking skills

• Excellent interpersonal skills

• Ability to exercise judgement and critical thinking skills

• Ability to work in a team environment

• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT

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

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

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.

Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com