Disability Representative Sr

Sedgwick is a leading claims management services company, and they are seeking a Disability Representative Sr to provide disability case management and complex claim determinations. The role involves making independent claim determinations, analyzing medical information, and managing disability claims to ensure timely payments and compliance with guidelines.

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 (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan
• Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed
• Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets
• Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system
• Communicates with the claimants’ providers to set expectations regarding return to work
• Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions
• Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and/or claims system
• Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims
• Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/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(s) minimum requirements
• Performs other duties as assigned