Clinical Reviewer

Telecommuter MI Telecommuter TX Telecommuter WI Telecommuter IA Full time

R78916

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance

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. 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 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 Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. #J-18808-Ljbffr Sedgwick