Disability Representative Sr

Sedgwick; South Portland (ME); Hybrid; USD 29,000 - 40,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401k and matching

PTO

Disability and life insurance

Employee assistance

Flexible spending account

Health savings account

Job summary

Sedgwick seeks an experienced Disability Representative Sr to manage complex disability claims, interpret medical documentation, and determine benefits under the disability plan. The role includes negotiating returns to work, coordinating with providers, and ensuring timely payments.

A strong background in ERISA, FMLA, and medical terminology is required, with a focus on client service. Candidates should have a High School diploma or GED, with a Bachelor's degree preferred, and at least three

Qualifications

• Knowledge of ERISA regulations, offsets and deductions.
• Understanding of FMLA regulations and disability practices.
• Proficiency in medical terminology and duration management.

Responsibilities

• Make independent claim determinations on complex disability cases.
• Review complex medical information to determine disability status.
• Coordinate referrals to outside vendors or physician reviews.
• Negotiate return-to-work with employers and physicians.
• Maintain client relationships and meet quality standards.

Skills

ERISA regulations

FMLA regulations

Medical terminology

Communication skills

Microsoft Office

Analytical thinking

Team player

Education

High School diploma or GED

Bachelor's degree preferred

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 Sr

Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence:

Dubuque, IA : 4141 Westmark Drive, Dubuque, IA 52002

Cedar Rapids, IA : 333 1st Street SE Ste. 200 Cedar Rapids IA 52401

Coralville, IA : 3273 Ridgeway Drive Coralville IA 52241

Dublin, OH : 5500 Glendon Court Dublin OH 43016

New Albany, OH : 7795 Walton Parkway New Albany, OH 43054

Chicago, IL : 175 W. Jackson Blvd. 12th Fl. Chicago IL 60604

Indianapolis, IN : 8909 Purdue Road Suite 501 Indianapolis, IN 46268

Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063

Memphis, TN : 8125 Sedgwick Way, Memphis TN 38125

Southfield, MI : 300 Galleria Officentre Southfield MI 48034

Orlando, FL : 12650 Ingenuity Dr Orlando FL 32826

Eden Prairie, MN : 11000 Prairie Lakes Drive Eden Prairie, MN 55344

West Hills, CA : 8521 Fallbrook Ave West Hills, CA 91304

PRIMARY 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 RESPONSIBILITIES

• Makes 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 RESPONSIBILITIES

• Performs other duties as assigned.

QUALIFICATIONS

Education & Licensing

High 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.

Experience

Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and 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
• Ability to manage ambiguity
• 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 autonomously within established procedures

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

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 $20.78 - $29.09 USD Hourly. 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.

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.