Disability Representative Sr

Sedgwick•Cedar Rapids, IA

11d

About The Position

The Disability Representative Sr provides disability case management and makes complex claim determinations using medical documentation and applicable disability plan interpretations. The role determines benefits due and makes timely payments, approvals, and adjustments. It medically manages disability claims involving comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigations; reviews contested claims; negotiates return to work with or without accommodations; and evaluates and arranges appropriate referrals to outside vendors.

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.
Ability to sit at a desk for extended periods while operating a computer and phone system.
Ability to travel as required.
Hearing, vision, and talking abilities as required.

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

Independently determine whether complex disability claims should be approved based on information received and the disability plan, or recommend denial to a team lead.
Review and analyze complex medical information, including attending physician statements, office notes, and operative reports, to determine whether a claimant meets the plan’s definition of disability.
Oversee complex claim issues, including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines.
Use appropriate clinical resources in case assessments, such as duration guidelines and in-house clinicians.
Determine benefits due under the disability plan and make timely claims payments, approvals, and adjustments for workers’ compensation, Social Security Disability Income, and other disability offsets.
Inform claimants about required documentation, deadlines, 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 appropriate referrals to outside vendors or 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.