PRIMARY PURPOSE

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.

ESSENTIAL

FUNCTIONS and

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.

ADDITIONAL

FUNCTIONS and

RESPONSIBILITIES

Performs other duties as assigned.

QUALIFICATIONS

Education & Licensing High School diploma or GED required. 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. Experience Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred. Skills & Knowledge 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

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. 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. 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