Advocacy Coordination Team Specialist

PRIMARY PURPOSE Actively researches, resolves, and administers escalated inquiries for all lines of business, including 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, interpretation of regulations, financial payment processing, and error correction of complex or high exposure claims. ESSENTIAL FUNCTIONS and RESPONSIBILITIES Make independent claim determinations, approve complex claims or recommend denial based on requirements. Analyze and authorize leave, accommodation, disability, and statutory claims to determine benefits due following client plans, state and federal regulations. Enter and adjust payments and evaluate file interface to support payment research and resolution. Communicate clearly and professionally with claimants and clients on all aspects of the claims process, including approval decisions, decision authority levels, and issue resolution via phone or written correspondence. Facilitate claim resolution and handle escalated calls with claimants, HR managers, treating physician’s office, client, or others with a goal of one‑call resolution. Ensure claims files are coded correctly and documentation is adequate. Review and analyze complex medical information (diagnostic tests, office notes, operative reports, etc.) to determine disability status as defined by the disability plan and manage claims to completion. Inform claimants and clients of required documentation, timeframes, payment information, and claim status. Determine benefits due, make timely and accurate claims payments/approvals and adjustments for workers’ compensation, Social Security Disability Income (SSDI), and other disability offsets. Maintain professional client relationships and adhere to client‑specific requirements such as service level expectations, regulatory requirements, and reporting. Meet the organization’s quality program(s) 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 college or university preferred. Experience: Three (3) years of related experience or equivalent combination of experience and education required, including 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 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. Reasonable accommodations will be considered when applicable. 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. COMPENSATION & BENEFITS As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency. For the jurisdiction noted in this job posting only, the starting pay for this role is $23.50‑$25.50 per hour. A comprehensive benefits package is offered: medical, dental, vision, 401(k) and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, 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