Remote Clinical Claims Specialist

Sedgwick; Dubuque (IA); Remote; USD 65,000 - 85,000; Full time

Job summary

Sedgwick, a leading risk and claims solutions provider, seeks a Clinical Specialist to perform standard clinical evaluations on disability claims requiring expert review. You will consult with providers and employees, determine the medical necessity for absence from work, and ensure documentation supports decisions.

Responsibilities include analyzing medical records, communicating status with stakeholders, and providing recommendations for ongoing management.

Qualifications

• Bachelor's degree or equivalent preferred.
• Current CRC License required.
• Current license, registration and/or professional designations as required within the jurisdiction.
• CEUs to maintain licenses and designations.

Responsibilities

• Performs standard clinical reviews of referred medical claims based on client requirements to ensure accurate and sufficient information is received by employees and providers to support the claim request and documents decision rationale.
• Completes medical review of all claims by reviewing medical documentation and applying clinical knowledge to substantiate disability and impact on job functions.
• Communicates with employees and providers to discuss clinical status, progress, and work status.
• Provides follow-up recommendations for ongoing medical management of claims; ensures recommendations are made on claims.
• Achieves quality audit scores.
• Acts as clinical resource to claims examiners for medical management guidance.
• Backups for key disability claims as needed.
• Travels as required.

Job description

Sedgwick, a leading risk and claims solutions provider, seeks a Clinical Specialist to perform standard clinical evaluations on disability claims requiring expert review. You will consult with providers and employees, determine the medical necessity for absence from work, and ensure documentation supports decisions.

Responsibilities include analyzing medical records, communicating status with stakeholders, and providing recommendations for ongoing management.