Disability Representative

By joining Sedgwick, you’ll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

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Disability Representative

Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence:

Dublin, OH : 5500 Glendon Court Dublin OH 43016

PRIMARY PURPOSE
:
Provides disability case management and routine claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims; coordinates investigative efforts, thoroughly reviewing contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors.

• Makes claim determinations, based on the information received, to approve routine disability claims or makes a recommendation to team lead to deny claims based on the disability plan.
• Reviews and analyzes routine medical information (i.e. attending physical statements, office notes, off work notes, etc.) or consults with a nurse to determine if the claimant is disabled as defined by the disability plan.
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians) regularly.
• Determines benefits due, makes timely claims payments 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 routine 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 as appropriate to team lead and clinical case management to assist with claim determination.
• Meets the organization's quality program(s) minimum requirements.
• Maintains professional client relationships and provides excellent customer service.

• Performs other duties as assigned.

Education & Licensing

High school diploma or GED required. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.

Experience

Two (2) years of related experience or equivalent combination of education and experience required. One (1) year of office or customer service experience required. One (1) year of benefits or claims management experience preferred.

Skills & Knowledge

• 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