Disability Representative Sr

Sedgwick•Cedar Rapids, IA

1d•$23 - $25

About The Position

Provides disability case management and makes complex claim determinations based on medical documentation and interpretation of applicable disability plans. The role determines benefits due and processes timely payments, approvals, and adjustments; medically manages complex disability claims, including those 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 or other resources. The representative communicates with claimants, providers, and clients about claim documentation, timelines, payments, status, and return-to-work expectations. The role maintains client relationships, provides customer service, and meets applicable quality program requirements.

Requirements

High school diploma or GED.
Three years of benefits or disability case/claims management experience, or an equivalent combination of education and experience, preferred.
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 handle work-related stress, multiple priorities, and deadlines.
Ability to sit at a desk for extended periods while operating a computer and phone system; travel as required.
Hearing, vision, and talking ability.

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.

Responsibilities

Independently determine whether complex disability claims should be approved based on available information and the disability plan, or recommend denial to a team lead.
Review and analyze complex medical documentation to determine whether a claimant meets the disability 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 as needed.
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 return-to-work expectations.
Medically manage complex disability claims in accordance 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 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 minimum requirements of the organization’s quality programs.
Perform other duties as assigned.