Disability Representative Sr

Sedgwick•Eden Prairie, MN

8d•Hybrid

About The Position

The Disability Representative Sr provides disability case management and makes claim determinations based on complex medical documentation and applicable disability plan interpretation. The role determines benefits due; makes timely payments, approvals, and adjustments; medically manages disability claims; coordinates investigative efforts; reviews contested claims; negotiates return to work with or without job accommodations; and evaluates and arranges appropriate referrals to outside vendors. This role analyzes assigned claims and complex medical information to determine whether claimants meet the disability plan definition. It uses clinical resources, applies duration control guidelines and plan provisions, calculates benefits and offsets, and communicates with claimants, clients, providers, and employers throughout the claims process. The position collaborates with team leads and clinical case management when appropriate. The teams collaborate in the office one day a week for a connection day. The Eden Prairie office is at 11000 Prairie Lakes Drive, Eden Prairie, MN 55344. A credit security clearance confirmed through a background credit check is required. Reasonable accommodations will be considered when applicable and appropriate.

Requirements

Three years of benefits or disability case/claims management experience, or an equivalent combination of education and experience.
Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices, and Social Security application procedures.
Working knowledge of medical terminology and duration management.
Excellent oral and written communication skills, including presentation skills.
PC literacy, including Microsoft Office products.
Analytical and interpretive skills.
Strong organizational skills.
Ability to work in a team environment.
Excellent negotiation skills.
Ability to meet or exceed performance competencies.
Credit security clearance confirmed via a background credit check.
Ability to handle work-related stress, multiple priorities, and deadlines; clear and conceptual thinking, sound judgment, troubleshooting, problem-solving, analysis, and discretion.
Ability to perform computer keyboarding and travel as required.
Hearing, vision, and talking abilities.

Nice To Haves

Bachelor’s degree from an accredited university or college preferred.

Responsibilities

Analyze, approve, and authorize assigned claims and determine benefits due under a disability plan.
Review and analyze complex medical information, including diagnostic tests, office notes, and operative reports, to determine whether a claimant is disabled under the plan.
Use appropriate clinical resources in case assessment, such as duration guidelines and in-house clinicians.
Communicate with claimants’ providers to set expectations regarding return to work.
Determine benefits due and make timely claims payments, approvals, and adjustments for workers’ compensation, Social Security Disability Income (SSDI), and other disability offsets.
Medically manage disability claims in compliance with duration control guidelines and plan provisions.
Communicate clearly with claimants and clients about all aspects of the claims process by phone and/or written correspondence.
Inform claimants of required documentation, time frames, payment information, and claim status by phone, written correspondence, and/or the claims system.
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, and 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.
Maintain professional client relationships.
Perform other duties as assigned and support the organization’s quality programs.