Disability Specialist

Primary Purpose Provides disability case management and routine claim determinations based on medical documentation and the applicable disability plan. The role involves determining benefits due, making timely payments or approvals, medically managing disability claims, coordinating investigative efforts, reviewing contested claims, negotiating return‑to‑work arrangements, and arranging referrals to outside vendors. Essential Functions and Responsibilities Make claim determinations, approving routine disability claims or recommending denial to a team lead based on the disability plan. Review and analyze routine medical information, consult with a nurse if needed, and determine if the claimant is disabled as defined by the plan. Utilize appropriate clinical resources (e.g., duration guidelines, in‑house clinicians) for case assessment. Determine benefits due and make timely claims payments or adjustments for workers’ compensation, SSDI, and other disability offsets. Inform claimants of documentation requirements, time frames, payment information, and claims status by phone, written correspondence, and/or the claims system. Communicate with claimants’ providers to set expectations regarding return to work. Medically manage routine disability claims to ensure compliance with duration control guidelines and plan provisions. Communicate clearly and promptly with claimants and clients regarding all aspects of the claims process. Coordinate investigative efforts, ensuring appropriateness, and provide a thorough review of contested claims. Evaluate and arrange appropriate referral of claims to outside vendors (e.g., physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation). Negotiate return to work with or without job accommodations via the claimant’s physician and employer. Refer cases as appropriate to the team lead and clinical case management for assistance with claim determination. Meet the organization’s quality program(s) minimum requirements and maintain professional client relationships, providing excellent customer service. Additional Functions and Responsibilities Perform other duties as assigned. Qualifications High school diploma or GED required. Must have at least two (2) years of related experience or an equivalent combination of education and experience. At least one (1) year of office or customer service experience required. One (1) year of benefits or claims management 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 skills, including presentation skills. Proficient computer skills, including working knowledge of Microsoft Office. Strong analytical, interpretive, and critical‑thinking skills. Strong organizational and multitasking skills. Ability to work in a team environment. Ability to meet or exceed performance competencies as required by the program. Effective decision‑making and negotiation skills. Ability to exercise judgment with limited supervision. Work Environment When applicable and appropriate, reasonable accommodations will be considered. Credit security clearance, confirmed via a background credit check, is required. 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 speaking required. Mental: Clear conceptual thinking, excellent judgment, discretion, stress tolerance, ability to handle multiple priorities, and meet deadlines. Benefits Medical, dental, and vision coverage 401(k) with matching Paid time off (PTO) Disability and life insurance Employee assistance program Flexible spending or health savings account options Additional voluntary benefits Payment range in the California jurisdiction: $22.00 to $24.00 per hour. Equal Opportunity Employer Sedgwick is an Equal Opportunity Employer and a Drug‑Free Workplace. Qualified applicants are considered in accordance with the relevant Fair Chance ordinances and the California Fair Chance Act. #J-18808-Ljbffr Sedgwick Claims Management Services Ltd