Disability Representative Sr

Sedgwick•Dublin, OH

19h•Onsite

About The Position

Sedgwick is the world’s leading risk and claims administration partner, helping clients navigate the unexpected with expertise and AI-enabled technology in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick offers a caring culture and work-life balance. The Disability Representative Sr role involves providing disability case management and complex claim determinations based on medical documentation and disability plan interpretation. This includes determining benefits, making timely payments, medically managing claims with comorbidities, concurrent plans, and complex ADA accommodations, coordinating investigations, reviewing contested claims, negotiating return to work, and arranging referrals to outside vendors.

Requirements

High School diploma or GED required.
Three (3) years of benefits or disability case/claims management experience or 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.
Knowledge of state and federal FMLA regulations.
Working knowledge of medical terminology and duration management.
Excellent oral and written communication, 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 program.
Effective decision-making and negotiation skills.
Ability to exercise judgement autonomously within established procedures.

Nice To Haves

Bachelor's degree from an accredited university or college preferred.
State certification or licensing in statutory leaves is preferred or may be required based on state regulations.

Responsibilities

Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan.
Reviews and analyzes complex medical information (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan.
Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed.
Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system.
Communicates with the claimants’ providers to set expectations regarding return to work.
Medically manages complex disability claims ensuring compliance with duration control guidelines and plan provisions.
Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and/or claims system.
Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
Negotiates return to work with or without job accommodations via the claimant’s physician and employer.
Refers cases to team lead and clinical case management for additional review when appropriate.
Maintains professional client relationships and provides excellent customer service.
Meets the organization’s quality program(s) minimum requirements.
Performs other duties as assigned.