Disability Representative

Sedgwick; Los Angeles (CA); On-site; USD 57,308,000 - 80,231,000; Full time

Benefits offered by this job

Medical, dental, vision

401k and matching

PTO

Disability and life insurance

Employee assistance

FS/HSAs offered

Job summary

Sedgwick in Los Angeles is seeking a Disability Representative to assess claims, determine benefits, and coordinate return-to-work plans based on medical documentation and plan interpretation, ensuring timely payments and appropriate adjustments.

You will review medical records, consult clinical resources, communicate clearly with claimants and providers, and collaborate with teams to ensure accuracy, compliance with ERISA and FMLA, and high-quality service standards.

Qualifications

• Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management.
• Knowledge of state and federal FMLA regulations.
• Strong oral and written communication skills and ability to interpret medical information.
• Proficiency with Microsoft Office and claim processing systems.

Responsibilities

• Makes claim determinations and approves routine disability claims or recommends denial as per plan.
• Reviews medical information to determine disability status and benefits due.
• Communicates with claimants and providers to set expectations and provide updates.
• Coordinates investigations and referrals to outside vendors or medical reviews.
• Negotiates return-to-work with or without accommodations and ensures timely payments.
• Maintains quality program compliance and excellent client service.

Skills

ERISA regulations

FMLA regulations

Medical terminology

Communication skills

MS Office

Analytical thinking

Education

High school diploma or GED

Tools

MS 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.

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 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.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. 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. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $24.00. 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.

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.

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.