Hybrid Disability Claims Specialist

Sedgwick Claims Management Services Ltd; Southfield (MI); Hybrid; USD 60,000 - 85,000; Full time

Job summary

Sedgwick is seeking a Sr Disability Representative to perform complex disability claim determinations and medical reviews in a hybrid setting near Southfield, MI. You will coordinate with treating physicians, plan provisions, and outside reviewers to ensure accurate benefit decisions.

The role requires interpreting ERISA and FMLA guidelines, timely communications with claimants and clients, and a strong collaboration with medical staff.

Qualifications

• 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.

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 to determine if the claimant is disabled as defined by the disability plan.
• Oversees additional facets of complex claims including comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
• Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, SSDI, and other disability offsets.
• Informs claimants of documentation required to process claims, required time frames, payment information and claims status.
• Communicates with the claimants’ providers to set expectations regarding return to work.

Skills

ERISA knowledge

FMLA knowledge

Medical terminology

Oral & written communication

Microsoft Office

Analytical thinking

Teamwork

Decision making

Negotiation

Autonomy

Education

High School diploma or GED

Bachelor's degree preferred

Job description

Sedgwick is seeking a Sr Disability Representative to perform complex disability claim determinations and medical reviews in a hybrid setting near Southfield, MI. You will coordinate with treating physicians, plan provisions, and outside reviewers to ensure accurate benefit decisions.

The role requires interpreting ERISA and FMLA guidelines, timely communications with claimants and clients, and a strong collaboration with medical staff.