Senior Disability Claims Specialist - Complex Cases

Sedgwick Claims Management Services Ltd; Dublin, Northern (OH, KY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Sedgwick Claims Management Services Ltd seeks a Sr Disability Representative in Dublin, OH to drive disability case management and complex claim determinations based on medical documentation and plan interpretations. You will coordinate return-to-work strategies, review contested claims, and ensure timely payments and appropriate referrals to specialists.

Ideal candidates have a Bachelor's degree (preferred), 3+ years in disability or benefits claims, strong knowledge of ERISA and FMLA, and

Qualifications

• Three 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 to approve complex disability claims or recommends denial to team lead.
• Reviews and analyzes complex medical information to determine disability status as defined by the plan.
• Oversees comorbidities, concurrent plans, ADA accommodations, and claims outside typical guidelines.
• Determines benefits due and ensures timely payments/adjustments for workers' comp, SSDI, and offsets.
• Informs claimants of documentation and timelines, provides status updates by phone, mail, or claims system.
• Communicates with providers to set expectations regarding return to work.
• Manages complex disability claims with compliance to duration guidelines and plan provisions.
• Coordinates referrals to outside vendors or physician advisors as needed.
• Negotiates return to work with or without accommodations.
• Maintains professional client relationships and supports quality programs.

Skills

ERISA knowledge

FMLA knowledge

Medical terminology

MS Office

Analytical skills

Communication skills

Negotiation

Decision making

Teamwork

Time management

Education

High School diploma or GED

Bachelor's degree preferred

State certification/licensing in statutory leaves

Tools

Claims system

Microsoft Office

Job description

Sedgwick Claims Management Services Ltd seeks a Sr Disability Representative in Dublin, OH to drive disability case management and complex claim determinations based on medical documentation and plan interpretations. You will coordinate return-to-work strategies, review contested claims, and ensure timely payments and appropriate referrals to specialists.

Ideal candidates have a Bachelor's degree (preferred), 3+ years in disability or benefits claims, strong knowledge of ERISA and FMLA, and