Disability Representative

Sedgwick Claims Management Services Ltd; Fallbrook, Los Angeles (CA, CA); On-site; USD 52,000 - 64,000; Full time

Benefits offered by this job

Comprehensive benefits package

PTO and leave benefits

401k and matching

Job summary

Sedgwick Claims Management Services Ltd is hiring for a disability representative to manage routine disability claims based on medical documentation and plan interpretation. You will determine benefits due, process payments, and coordinate return-to-work with or without accommodations, ensuring alignment with ERISA and FMLA requirements.

You will review medical information, communicate clearly with claimants and providers, and coordinate with clinical staff and outside vendors as needed.

Qualifications

• High school diploma or GED required; state certification/licensing in statutory leaves preferred or may be required.
• Two years of related experience; one year in office or customer service; one year in benefits or claims management preferred.
• Knowledge of ERISA, FMLA, disability duration and medical management; strong communication skills; proficient in Microsoft Office.

Responsibilities

• Make claim determinations to approve routine disability claims or recommend denial.
• Review medical information to determine if the claimant is disabled per the plan.
• Coordinate with nurses and in-house clinicians; manage duration and benefits.
• Inform claimants about documentation, timelines, and status via phone, mail, or claims system.
• Communicate with providers to set expectations on return to work.
• Medically manage routine disability claims and ensure plan compliance.
• Coordinate outside vendors or physician reviews as needed.
• Negotiate return to work with or without accommodations.

Skills

ERISA regulations knowledge

FMLA regulations knowledge

Medical terminology knowledge

Oral and written communication

Analytical thinking

Team collaboration

Decision making

Negotiation skills

Customer service

Education

High school diploma or GED

Tools

Microsoft Office

Job description

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 Disability Representative

PRIMARY PURPOSE

Provides disability case management and routine 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; coordinates investigative efforts, thoroughly reviewing 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 claim determinations, based on the information received, to approve routine disability claims or makes a recommendation to team lead to deny claims based on the disability plan.
• Reviews and analyzes routine medical information (i.e. attending physical statements, office notes, off work notes, etc.) or consults with a nurse to determine if the claimant is disabled as defined by the disability plan.
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians) regularly.
• Determines benefits due, makes timely claims payments 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 routine 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 as appropriate to team lead and clinical case management to assist with claim determination.
• Meets the organization’s quality program(s) minimum requirements.
• Maintains professional client relationships and provides excellent customer service.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

QUALIFICATIONS

Education & Licensing

High school diploma or GED required. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.

Experience

Two (2) years of related experience or equivalent combination of education and experience required. One (1) year of office or customer service experience required. One (1) year of benefits or claims management experience preferred.

Skills & Knowledge

• Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
• Knowledge of state and federal FMLA regulations
• Working knowledge of medical terminology and duration management
• Excellent oral and written communication, including presentation skills
• Proficient computer skills including working knowledge of Microsoft Office
• Analytical, interpretive, and critical thinking skills
• Strong organizational and multitasking skills
• Ability to work in a team environment
• Ability to meet or exceed performance competencies as required by program
• Effective decision-making and negotiation skills
• Ability to exercise judgement with limited supervision

When applicable and appropriate, consideration will be given to reasonable accommodations. Mental: Clear and conceptual thinking ability; excellent judgment 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

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.

For the jurisdiction noted in this job posting only, the range of starting pay for this role is 25.09

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.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience.

For more, see sedgwick.com