Disability Clinical Specialist

Sedgwick • Sugarcreek, PA

34d

About The Position

Performs standard clinical evaluations of claims requiring additional review based on medical condition, client requirements, or complexity. Consults with providers and employees, provides case direction, and ensures medical information substantiates the need for an employee’s absence from work. The role also acts as a clinical resource to claims examiners and may provide backup support for key disability claims.

Requirements

• Current RN, LVN, LPN, CRC, COHN, CVE, LPC, and/or LCSW license(s) required, as applicable.
• Maintain current licenses, registrations, and professional designations required within the jurisdiction, including acquisition of necessary continuing education units.
• Four years of related experience, or an equivalent combination of experience and education, including experience in a direct medical/psychological setting or physical industrial medicine and previous insurance or related experience.
• Knowledge of current health care management practices across areas including orthopedics, acute and chronic general medicine, general surgery, mental health, obstetrics, oncology, and physical and occupational rehabilitation.
• Excellent oral and written communication skills, including presentation skills.
• Proficient computer skills, including working knowledge of Microsoft Office.
• Analytical and interpretive skills.
• Strong organizational and multitasking skills.
• Excellent interpersonal skills.
• Ability to exercise judgment and critical thinking skills.
• Ability to work in a team environment.
• Ability to meet or exceed Performance Competencies.

Nice To Haves

• Bachelor’s degree or equivalent preferred.

Responsibilities

• Perform standard clinical reviews of referred medical claims based on client requirements, ensuring sufficient information is obtained from employees and providers and documenting the decision rationale.
• Review medical documentation and apply clinical knowledge to determine whether information substantiates disability and how a condition affects the employee’s ability to perform job functions.
• Communicate professionally by phone and/or in writing with employees and providers about clinical status, progress, and work status.
• Provide appropriate follow-up recommendations for ongoing medical management of claims.
• Achieve appropriate quality audit scores.
• Guide claims examiners on medical claim management, medical terminology, and substantiating claim decisions.
• Provide ad hoc backup for key disability claims.
• Perform other duties as assigned.
• Travel as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed