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 provisions. The role determines benefits due, makes timely payments and adjustments, medically manages claims, coordinates investigations, reviews contested claims, negotiates return to work with or without accommodations, and evaluates and arranges referrals to outside vendors and clinical resources. The specialist communicates with claimants, clients, providers, and employers throughout the claims process; reviews medical information and applies clinical resources and duration guidelines; and refers cases to team leads or clinical case management when appropriate. The role is expected to meet quality requirements, maintain professional client relationships, and provide excellent customer service.

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.
Ability to meet or exceed performance competencies as required by the program.
Effective decision-making and negotiation skills.
Ability to exercise judgment with limited supervision.

Nice To Haves

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

Responsibilities

Make claim determinations to approve routine disability claims or recommend denial to a team lead based on the disability plan.
Review and analyze routine medical information, or consult with a nurse, to assess whether a claimant is disabled under the plan.
Use appropriate clinical resources in case assessment, including duration guidelines and in-house clinicians.
Determine benefits due and make timely claims 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 expectations regarding return to work.
Medically manage routine disability claims in compliance with duration control guidelines and plan provisions.
Communicate clearly and promptly with claimants and clients about all aspects of the claims process.
Coordinate investigative efforts and thoroughly review contested claims.
Evaluate and arrange appropriate referrals to outside vendors or physician advisor reviews, surveillance, independent medical evaluations, functional capability evaluations, or related disability activities.
Negotiate return to work, with or without job accommodations, through the claimant’s physician and employer.
Refer cases to the team lead and clinical case management as appropriate to assist with claim determination.
Meet the organization’s minimum quality program requirements.
Maintain professional client relationships and provide excellent customer service.
Perform other duties as assigned.