Disability Clinical Specialist

Sedgwick

5d•$62,000 - $63,000

About The Position

Performs standard clinical evaluations of disability claims requiring additional review because of the medical condition, client requirements, or claim complexity. The specialist consults with providers and employees, provides case direction, and determines whether medical information substantiates an employee’s absence from work. The role also serves as a clinical resource to claims examiners on medical claim management and decision support. The position requires reviewing medical documentation, applying clinical knowledge to assess disability and its impact on job functions, communicating with employees and providers about clinical status and work status, and recommending appropriate follow-up medical management. Travel may be required. The work involves extended periods seated at a desk while using a computer and phone system, along with mental demands such as handling multiple priorities, solving problems, and meeting deadlines.

Requirements

Current RN, CRC, LPC, and/or LCSW license(s) required.
Maintain current licenses and professional designations, including acquiring necessary continuing education units.
Four years of related experience, or an equivalent combination of experience and education, including experience in a direct medical or psychological setting or physical industrial medicine and previous insurance or related experience.
Knowledge of current health care management practices across areas including orthopedics, 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.
Ability to sit at a desk for extended periods while operating a computer and phone system.
Ability to handle work-related stress, multiple priorities, and deadlines.

Nice To Haves

Bachelor’s degree or equivalent preferred.

Responsibilities

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