Sr. Disability Representative

Primary Purpose Provide 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, coordinating investigative efforts, reviewing contested claims, negotiating return to work, and arranging appropriate referrals to outside vendors. Essential Functions and Responsibilities Make independent claim determinations or recommend denial based on the disability plan. Review and analyze complex medical information to determine claimant eligibility. Oversee additional facets of complex claims such as comorbidities, concurrent plans, ADA accommodations, and claims outside typical guidelines. Utilize appropriate clinical resources for case assessment, including duration guidelines and in‑house clinicians. Determine benefits due and make timely claims payments/approvals and adjustments for workers compensation, SSDI, and other disability offsets. Inform claimants of required documentation, time frames, payment information, and claims status by phone, written correspondence, or claims system. Communicate with claimants’ providers regarding return‑to‑work expectations. Medically manage complex disability claims to ensure compliance with duration control guidelines and plan provisions. Coordinate investigative efforts and provide thorough review of contested claims. Evaluate and arrange referral of claims to outside vendors or physician advisory reviews, surveillance, independent medical evaluations, functional capability evaluations, and 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. Perform other duties as assigned. Additional Functions and Responsibilities Perform other duties as assigned. Qualifications High School diploma or GED required; Bachelor’s degree preferred. State certification or licensing in statutory leaves preferred or may be required. Three (3) years of benefits or disability case/claims management experience or equivalent education and experience. Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices, 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 Microsoft Office. Analytical, interpretive, and critical thinking skills. Ability to manage ambiguity, meet or exceed performance competencies, and exercise judgment autonomously within established procedures. Strong organizational and multitasking skills and ability to work in a team environment. Effective decision‑making and negotiation skills. Work Environment Reasonable accommodations will be considered when applicable. Physical demands include extended periods at a desk using a computer and phone system. Travel may be required. Benefits A comprehensive benefits package is offered, including medical, dental, vision, 401(k) with matching, PTO, disability and life insurance, employee assistance, flex spending or health savings account, and other voluntary benefits. EEO Statement Sedgwick is an Equal Opportunity Employer and a Drug‑Free Workplace. Qualified applicants with arrest or conviction records will be considered for employment in accordance with applicable Fair Chance Ordinances and laws. #J-18808-Ljbffr Sedgwick Claims Management Services Ltd