PRIMARY PURPOSE

: Actively researches, resolves, and administers escalated inquires for all lines of business, including but not limited to Family Medical Leave ( FMLA ), complex paid and unpaid state, military, and company-specific leaves, accommodations, disability and statutory claims. Provides excellent customer service displaying care and empathy to callers regarding claims and executes technical and jurisdictional requirements for accurate claims processing, benefit review and interpretation of regulations, financial payment processing, and error correction of complex or high exposure claims.

ESSENTIAL

FUNCTIONS and

RESPONSIBILITIES

+ Makes independent claim determinations, based on the information received, to approve complex claims or make a recommendation to team lead to deny claims based on the requirements. + Analyzes and authorizes leave, accommodation, disability, and statutory claims and determines benefits due pursuant to client plans, and state and federal regulations. + Enters and adjusts payments and evaluates file interface to support payment research and resolution. + Communicates clearly and professionally with claimant and client on all aspects of the claims process including claim approval, decision authority level to move the call forward, and issue resolution by phone, written correspondence and/or claims system. + Facilitates claim resolution and handles escalated calls with claimant, human resources managers, treating physician's office, client, or others with a goal of one-call resolution. + Ensures claims files are coded correctly and that adequate documentation is in the claim. + Reviews and analyzes complex medical information (i.e. diagnostic tests, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan and takes all necessary action to manage claims process to completion. + Informs claimants and client of documentation required to process claims, required timeframes, payment information and claims status. + Determines benefits due, makes timely and accurate claims payments/approvals and adjustments for workers compensation, Social Security Disability Income ( SSDI ), and other disability offsets. + Maintains professional client relationships and adheres to client specific requirements such as service level expectations, regulatory requirements, and reporting. + 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 college or university preferred. Experience Three (3) years of related experience or equivalent combination of experience and education required to include two (2) years of disability claims experience. Experience with

SMART , SIR , GAIN

, or other HR systems preferred. Experience with TAMS , Juris, viaOne express, and mySedgwick preferred for internal candidates. Skills & Knowledge + Knowledge of ERISA regulations, state and federal

FMLA , ADAAA

, Social Security application procedures, required offsets and deductions, and disability procedures + Working knowledge of medical terminology and duration management + Proficient computer skills including working knowledge of Microsoft Office + Exemplary call handling and de-escalation skills + Excellent interpersonal communication skills, oral and written + Analytical, interpretive, and critical thinking skills + Effective decision-making + Ability to manage ambiguity + Strong organizational and multitasking skills + Ability to exercise judgement autonomously within established procedures + Ability to work in a team environment + Ability to meet or exceed performance competencies as required by program

WORK ENVIRONMENT

Required to adhere to a set schedule with established break times. 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

NOTE :

Credit security clearance, confirmed via a background credit check, is required for this position. 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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