Disability Representative

Overview

Disability Representative. 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, reviews contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors.

Our West Hills Office is located at: 8521 Fallbrook Ave West Hills, CA 91304. We operate with a hybrid work arrangement in which teams collaborate in the office and/or remotely. Candidates must live near our West Hills Center of Excellence.

Be among the first 25 applicants for this opportunity and join a team recognized for quality and service.

• Makes claim determinations, based on the information received, to approve routine disability claims or makes a recommendation to the team lead to deny claims based on the disability plan.
• Reviews and analyzes routine medical information (e.g., attending physical statements, office notes, off work notes) or consults with a nurse to determine if the claimant is disabled as defined by the disability plan.
• Utilizes appropriate clinical resources in case assessment (e.g., duration guidelines, in-house clinicians).
• Determines benefits due, makes timely claims payments and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
• Informs claimants of required documentation, time frames, payment information, and claims status by phone, written correspondence, and/or claims system.
• Communicates with claimants’ providers to set expectations regarding return to work.
• Medically manages routine disability claims in compliance with duration control guidelines and plan provisions.
• Communicates clearly and timely with claimants and clients on all aspects of the 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 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 minimum requirements and maintains professional client relationships with excellent customer service.

• Performs other duties as assigned.

Education & Licensing

High school diploma or GED required.

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 Office
• Analytical, interpretive, and critical thinking skills
• 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 judgment with limited supervision

When applicable and appropriate, consideration will be given to reasonable accommodations. Mental, physical, and auditory/visual requirements are described in the original posting. Travel as required.

Note
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Credit security clearance, confirmed via a background credit check, is required for this position.

The…