Sr. Disability Representative

Sedgwick•Fallbrook, CA

9d•$26 - $28•Onsite

About The Position

Provides disability case management and complex claim determinations based on medical documentation and the applicable disability plan interpretation including determining benefits due and making timely payments/approvals and adjustments, medically managing disability claims including comorbidities, concurrent plans, and complex ADA accommodations; coordinates investigative efforts, thoroughly reviews contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors. Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape.

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 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, 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.