Disability Representative

Sedgwick Claims Management Services Ltd; Irving (TX); On-site; USD 42,000 - 62,000; Full time

Job summary

Sedgwick Claims Management Services Ltd is seeking a Disability Representative to evaluate disability claims, determine benefits, and manage routine payments. The role involves reviewing medical information, coordinating with providers, and ensuring timely decisions under disability plans.

The candidate will need to apply ERISA and FMLA knowledge, communicate clearly with claimants, and coordinate recoveries and referrals as part of end-to-end claims handling.

Qualifications

• Knowledge of ERISA regulations, required offsets and deductions, and disability duration and medical management practices.
• Familiarity with state and federal FMLA regulations and procedures.
• Proficiency in medical terminology and duration management; data entry and documentation accuracy.

Responsibilities

• Makes claim determinations to approve routine disability claims or recommends denial as needed.
• Reviews medical information or consults with a nurse to determine disability per plan.
• Communicates with claimants and providers about documentation, timelines, and status.
• Negotiates return to work with or without accommodations; coordinates referrals as needed.

Skills

ERISA rules

FMLA rules

Medical terminology

Education

High school diploma or GED

State certification/licensing in statutory leaves

Tools

Microsoft Office

Job description

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**WORK ENVIRONMENT**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 talkingThe 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.