Disability Representative Sr

Sedgwick•Orlando, FL

12d•$21 - $24

About The Position

The Senior Disability Representative provides disability case management and makes complex claim determinations based on medical documentation and interpretation of applicable disability plans. The role determines benefits due, makes timely payments, approvals, and adjustments, and medically manages claims involving comorbidities, concurrent plans, complex ADA accommodations, and circumstances outside typical guidelines. The representative 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 role communicates with claimants, clients, providers, and employers throughout the claims process; manages claims in accordance with plan provisions and duration control guidelines; and refers cases for additional review when appropriate. It also maintains client relationships, provides customer service, and meets organizational quality requirements.

Requirements

High school diploma or GED required.
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 as 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; 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 applicable plan.
Oversee complex claim issues, including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines.
Use appropriate clinical resources during case assessment, such as duration guidelines and in-house clinicians.
Determine benefits due under disability plans and make timely claims payments, approvals, and adjustments, including for workers’ compensation, SSDI, and other disability offsets.
Inform claimants about required documentation, time frames, payment information, and claim status by phone, correspondence, or 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 physician advisor reviews, surveillance, independent medical evaluations, functional capability evaluations, and related disability activities.
Negotiate return to work, with or without 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.