Disability Representative Sr

Sedgwick•Coralville, IA

About The Position

The Senior Disability Representative provides disability case management and makes complex claim determinations using medical documentation and applicable disability-plan provisions. The role determines benefits due and makes timely payment, approval, and adjustment decisions. It medically manages complex claims involving comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigations and reviews contested claims; negotiates return to work, with or without accommodations; and evaluates and arranges referrals to outside vendors and other resources. The representative communicates with claimants, providers, and clients throughout the claims process, maintains client relationships, and meets applicable quality-program requirements.

Requirements

High school diploma or GED.
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.
Ability to manage ambiguity.
Strong organizational and multitasking skills.
Ability to work in a team environment.
Ability to meet or exceed performance competencies required by the program.
Effective decision-making and negotiation skills.
Ability to exercise judgment autonomously within established procedures.

Nice To Haves

Bachelor’s degree from an accredited university or college.
State certification or licensing in statutory leaves, which may be required based on state regulations.
Three years of benefits or disability case/claims management experience, or an equivalent combination of education and experience.

Responsibilities

Make independent determinations to approve complex disability claims or recommend denial to a team lead based on the disability plan.
Review and analyze complex medical information to determine whether a claimant is disabled under the plan.
Oversee complex claim issues, including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines.
Use appropriate clinical resources, such as duration guidelines and in-house clinicians, when needed.
Determine benefits due under disability plans and make timely claims payments, approvals, and adjustments for workers’ compensation, SSDI, and other disability offsets.
Inform claimants of required documentation, time frames, payment information, and claim status through phone, correspondence, or the claims system.
Communicate with claimants’ providers to set expectations regarding return to work.
Medically manage complex 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 referrals to outside vendors or for 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 a team lead and clinical case management for additional review when appropriate.
Maintain professional client relationships and provide excellent customer service.
Meet the organization’s minimum quality-program requirements.
Perform other duties as assigned.