Senior Disability Claims Specialist

Sedgwick; Fallbrook (CA); On-site; USD 36,000 - 39,000; Full time

Benefits offered by this job

Medical

Dental

Vision

401k matching

Paid time off

Disability insurance

Life insurance

Employee assistance

FSAs/HSA

Voluntary benefits

Job summary

Sedgwick is seeking a Disability Representative Sr to manage complex disability claims, review medical data, and determine benefits under disability plans. The role involves coordinating with providers, agencies, and vendors to ensure accurate determinations and timely payments.

The position requires strong analytical, communication, and negotiation skills, with an emphasis on accurate case assessment and customer service within a collaborative team.

Qualifications

• Education: High School diploma or GED required; Bachelor’s degree preferred; state certification/licensing in statutory leaves preferred or may be required by state regulations.
• Experience: Three (3) years of benefits or disability case/claims management experience or equivalent.
• Skills & Knowledge: Knowledge of ERISA regs, FMLA, medical terminology; excellent communication and MS Office skills; analytical and negotiation abilities.

Responsibilities

• Makes independent claim determinations to approve or deny complex disability claims.
• Reviews complex medical information to determine disability per plan definitions.
• Oversees comorbidities, concurrent plans, and ADA accommodations in complex claims.
• Uses clinical resources for case assessment and duration guidance.
• Determines benefits due and processes timely payments/adjustments.
• Communicates documentation needs and status to claimants.
• Negotiates return to work with or without accommodations.
• Maintains professional relationships and supports quality programs.

Skills

ERISA regulations

FMLA regulations

Medical terminology

Communication skills

Microsoft Office

Analytical thinking

Team collaboration

Decision making

Education

Bachelor’s degree

Leaves licensing preferred

Tools

Microsoft Office

Job description

Sedgwick is seeking a Disability Representative Sr to manage complex disability claims, review medical data, and determine benefits under disability plans. The role involves coordinating with providers, agencies, and vendors to ensure accurate determinations and timely payments.

The position requires strong analytical, communication, and negotiation skills, with an emphasis on accurate case assessment and customer service within a collaborative team.