Senior Disability Claims Specialist

Sedgwick Claims Management Services Ltd; Dubuque (IA); On-site; USD 64,000 - 90,000; Full time

Job summary

Sedgwick Disability Representative Sr in Dubuque, IA is responsible for disability case management, reviewing medical documentation, determining benefits, and approving payments with complex coordination of plans and accommodations.

The role requires handling complex claims, negotiation of return-to-work, and ensuring compliance with ERISA, ADA, and FMLA, while maintaining strong client service.

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.
• Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.
• 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

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, ADA accommodations, and claims outside typical guidelines.
• Utilizes clinical resources in case assessment as needed.
• Determines benefits due pursuant to a disability plan, makes timely payments/approvals and adjustments for workers compensation, SSDI, and other offsets.
• Informs claimants of documentation required to process claims and status by phone or claims system.
• Communicates with the claimants’ providers to set expectations regarding return to work.
• Medically manages complex disability claims ensuring compliance with duration guidelines and plan provisions.
• Communicates clearly with claimant and client on all aspects of claims process.
• Coordinates investigative efforts ensuring appropriateness; provides review of contested claims.
• Evaluates and arranges referrals to outside vendors or physician advisor reviews, surveillance, 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 minimum requirements.

Skills

ERISA knowledge

FMLA regulations

Medical terminology

Communication skills

Microsoft Office

Analytical thinking

Teamwork

Decision making

Autonomous judgment

Education

High School diploma or GED

Bachelor's degree preferred

State certification/licensing in statutory leaves preferred

Tools

Microsoft Office

Job description

Sedgwick Disability Representative Sr in Dubuque, IA is responsible for disability case management, reviewing medical documentation, determining benefits, and approving payments with complex coordination of plans and accommodations.

The role requires handling complex claims, negotiation of return-to-work, and ensuring compliance with ERISA, ADA, and FMLA, while maintaining strong client service.