PRIMARY PURPOSE
: Performs standard clinical evaluations on claims that require additional review based on medical condition, client requirement, and/or complexity. Consults with providers and employees by providing case direction and ensures medical information substantiates the need for employee absence from work. This role is fully remote in the US.

•

ESSENTIAL

FUNCTIONS and

RESPONSIBILITIES

+ Performs standard clinical reviews of referred medical claims based on client requirements to ensure accurate and sufficient information is received by employees and providers to support the claim request and documents decision rationale.

+ Completes medical review of all claims by reviewing medical documentation received and applying practical clinical knowledge to ensure information substantiates disability and to interpret the impact the condition has on the ability to perform job functions. + Communicates clearly and professionally, on the phone and/or in writing with employee and/or providers to discuss employee's clinical status, progress, and work status. + Provides clear and appropriate follow-up recommendations for ongoing medical management of claims; ensures appropriate recommendations are made on claims. + Consistently achieves appropriate quality audit scores. + Acts as clinical resource to claims examiners to provide guidance on the medical management of claims including comprehension of medical terminology and substantiating claim decisions. •

ADDITIONAL

FUNCTIONS and

RESPONSIBILITIES

+ Acts as a backup for key disability claims on an ad hoc basis. + Performs other duties as assigned. + Travels as required.
QUALIFICATIONS
Education & Licensing
Bachelor's degree or equivalent preferred.
Current

RN, LVN, LPN, CRC, COHN

CVE, LPC and/or LCSW Licenses required.

Current license, registration and/or professional designations as required within the jurisdiction. Clinical expertise must be kept current by acquisition of the necessary CEUs to maintain licenses and designations.
Experience
Four (4) years of related experience or equivalent combination of experience and education required to include experience in a direct medical/psychological setting or physical industrial medicine and previous insurance or related experience.
Skills & Knowledge
+ Knowledge of current medical practices in health care management in a variety of areas (including, but not limited to, orthopedics, general medicine for acute and chronic conditions, general surgery, mental health, obstetrics, oncology, and physical and occupational rehabilitation) + Excellent oral and written communication, including presentation skills + Proficient computer skills including working knowledge of Microsoft Office + Analytical and interpretive skills + Strong organizational and multitasking skills + Excellent interpersonal skills + Ability to exercise judgement and critical thinking skills + Ability to work in a team environment + Ability to meet or exceed Performance Competencies •

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.
Mental:
Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines
Physical:
Ability to sit at a desk for extended periods while operating a computer and phone system. Travel as required.
Auditory/Visual:
Hearing, vision and talking The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description.

They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time. _As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the starting pay for this role is $62,500.00 USD Annual. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits._ Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.
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. For more, see

sedgwick.com

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