Advocacy Coordination Team Specialist

Sedgwick•Eden Prairie, MN

About The Position

The Advocacy Coordination Team Specialist provides disability case management and routine claim determinations based on medical documentation and applicable disability plan interpretations. The role determines benefits due, makes timely payments, approvals, and adjustments, medically manages disability claims, coordinates investigations, reviews contested claims, negotiates return-to-work plans with or without accommodations, and evaluates and arranges appropriate referrals to outside vendors. The specialist reviews routine medical information and may consult with a nurse to assess whether a claimant meets the disability plan’s definition of disability. The role communicates with claimants, clients, providers, and employers about documentation, timelines, payments, claim status, and return-to-work expectations. It also maintains professional client relationships, provides customer service, meets quality requirements, and refers cases to team leads or clinical case management when appropriate.

Requirements

High school diploma or GED.
Two years of related experience, or an equivalent combination of education and experience.
One year of office or customer service experience.
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 skills, 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 and meet or exceed program performance competencies.
Effective decision-making and negotiation skills.
Ability to exercise judgment with limited supervision.

Nice To Haves

State certification or licensing in statutory leaves, preferred or potentially required based on state regulations.
One year of benefits or claims management experience.

Responsibilities

Determine routine disability claims based on available information; approve claims or recommend denial to a team lead according to the disability plan.
Review and analyze routine medical information, or consult with a nurse, to determine whether a claimant is disabled under the plan.
Use appropriate clinical resources in case assessments, including duration guidelines and in-house clinicians.
Determine benefits due and make timely claim payments and adjustments for workers’ compensation, Social Security Disability Income (SSDI), and other disability offsets.
Inform claimants about required documentation, time frames, payment information, and claim status by phone, written correspondence, or claims system.
Communicate with claimants’ providers to set return-to-work expectations.
Medically manage routine disability claims in compliance with duration control guidelines and plan provisions.
Communicate clearly and promptly with claimants and clients throughout the claims process.
Coordinate investigative efforts and thoroughly review contested claims.
Evaluate and arrange referrals to outside vendors or physician-advisor reviews, surveillance, independent medical evaluations, functional capability evaluations, or related disability services.
Negotiate return to work, with or without job accommodations, through the claimant’s physician and employer.
Refer cases to a team lead or clinical case management when appropriate to assist with claim determinations.
Meet the organization’s minimum quality program requirements.
Maintain professional client relationships and provide excellent customer service.
Perform other duties as assigned.