Disability Representative Sr

Sedgwick Claims Management Services Ltd; Dubuque (IA); On-site; USD 65,000 - 90,000; Full time

Job summary

Sedgwick Claims Management Services Ltd in Dubuque, IA, is seeking a Senior Disability Representative to evaluate complex disability claims using medical data and plan provisions. You will determine benefits due, authorize payments, and coordinate vendor referrals as needed.

The role requires knowledge of ERISA, FMLA, SSDI, and durable negotiations for return to work with or without accommodations, plus strong communication, analytical, and multitasking skills.

Qualifications

• 3 years in benefits or disability case/claims management experience.
• Knowledge of ERISA regulations, required offsets and deductions, and disability duration.
• Knowledge of FMLA regulations and SSDI processes.
• Working knowledge of medical terminology and duration management.
• Excellent oral and written communication, including presentation skills.
• Proficient with Microsoft Office and data/document handling.
• Analytical, interpretive, and critical thinking abilities.
• Ability to work in a team and manage multiple priorities.

Responsibilities

• Makes independent claim determinations to approve complex disability claims or recommends denial to team lead.
• Reviews and analyzes complex medical information to determine disability status per plan.
• Oversees comorbidities, concurrent plans, ADA accommodations, and nonstandard claims.
• Determines benefits due, and makes timely payments/adjustments for workers' comp and SSDI.
• Informs claimants of documentation, time frames, and payment status by phone or claims system.
• Communicates with providers to set expectations regarding return to work.
• Medically manages complex disability claims ensuring duration guideline compliance.
• Coordinates investigations and reviews contested claims; refers to outside vendors when needed.
• Negotiates return to work with or without accommodations with physicians and employers.
• Refers complex cases to team lead and clinical review; maintains client relationships and service quality.

Skills

ERISA regulations

FMLA regulations

Disability case management

Medical terminology

Analytical thinking

Communication skills

Microsoft Office

Negotiation skills

Teamwork

Education

High School diploma or GED

Bachelor's degree preferred

State certification/licensing for statutory leaves preferred

Tools

Microsoft Office Suite

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 CompaniesCertified as a Great Place to WorkFortune Best Workplaces in Financial Services & InsuranceDisability Representative SrPRIMARY PURPOSE : Provides disability case management and complex 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 including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, thoroughly reviews 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 RESPONSIBILITIESMakes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan.Reviews and analyzes complex medical information (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed.Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals 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 complex 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 to team lead and clinical case management for additional review when appropriate.Maintains professional client relationships and provides excellent customer service.Meets the organization’s quality program(s) minimum requirements.ADDITIONAL FUNCTIONS and RESPONSIBILITIESPerforms other duties as assigned.QUALIFICATIONSEducation & LicensingHigh School diploma or GED required. Bachelor's degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.ExperienceThree (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.Skills & KnowledgeKnowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application proceduresKnowledge of state and federal FMLA regulationsWorking knowledge of medical terminology and duration managementExcellent oral and written communication, including presentation skillsProficient computer skills including working knowledge of Microsoft OfficeAnalytical, interpretive, and critical thinking skillsAbility to manage ambiguityStrong organizational and multitasking skillsAbility to work in a team environmentAbility to meet or exceed performance competencies as required by programEffective decision-making and negotiation skillsAbility to exercise judgement autonomously within established proceduresWORK ENVIRONMENTWhen 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 deadlinesPhysical : 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.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.