Disability Representative Sr

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 Make independent claim determinations based on the information received to approve complex disability claims or recommend to team lead to deny claims based on the disability plan. Review and analyze complex medical information (e.g., attending physician statements, office notes, operative reports) to determine if the claimant is disabled as defined by the disability plan. Oversee additional facets of complex claims, including comorbidities, concurrent plans, complex ADA accommodations, and claims outside typical guidelines. Utilize appropriate clinical resources in case assessment (e.g., duration guidelines, in‑house clinicians) as needed. Determine benefits due pursuant to a disability plan, making timely claim payments/approvals and adjustments for worker’s compensation, Social Security Disability Income (SSDI), and other disability offsets. Inform claimants of documentation required, required time frames, payment information, and claim status by phone, written correspondence, and/or claims system. Communicate with claimants’ providers to set expectations regarding return to work. Medically manage complex disability claims ensuring compliance with duration control guidelines and plan provisions. Coordinate investigative efforts ensuring appropriateness and provide thorough review of contested claims. Evaluate and arrange appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities. Negotiate return to work with or without job accommodations via the claimant’s physician and employer. Refer cases to team lead and clinical case management for additional review when appropriate. Maintain professional client relationships and provide excellent customer service. Meet the organization’s quality program minimum requirements. ADDITIONAL FUNCTIONS AND RESPONSIBILITIES Perform 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. Location All candidates must live near one of our centers of excellence: Dublin, OH 5500 Glendon Court Dublin OH 43016. COMPENSATION & BENEFITS For the jurisdiction noted in this job posting only, the starting pay range for this role is $21.00‑$25.00 USD hourly. A comprehensive benefits package is offered including, but not limited to: medical, dental, vision, 401(k) and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account (HSA), and other voluntary benefits. EEO STATEMENT Sedgwick is an Equal Opportunity Employer and a Drug‑Free Workplace. #J-18808-Ljbffr Sedgwick Claims Management Services Ltd