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.

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Disability Representative

PRIMARY PURPOSE: Provides disability case management and routine 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; coordinates investigative efforts, thoroughly reviewing 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

Makes claim determinations, based on the information received, to approve routine disability claims or makes a recommendation to team lead to deny claims based on the disability plan.Reviews and analyzes routine medical information (i.e. attending physical statements, office notes, off work notes, etc.) or consults with a nurse to determine if the claimant is disabled as defined by the disability plan.Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians) regularly.Determines benefits due, makes timely claims payments and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.Informs claimants of documentation required to process claims, required time frames, payment information and claims status by phone, written correspondence and/or claims system.Communicates with the claimants’ providers to set expectations regarding return to work.Medically manages routine disability claims ensuring compliance with duration control guidelines and plan provisions.Communicates clearly and timely with claimant and client on all aspects of claims process by phone, written correspondence and/or claims system.Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.Evaluates and arranges appropriate referral of claims to outside vendors or physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.Negotiates return to work with or without job accommodations via the claimant’s physician and employer.Refers cases as appropriate to team lead and clinical case management to assist with claim determination.Meets the organization’s quality program(s) minimum requirements.Maintains professional client relationships and provides excellent customer service.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

Performs other duties as assigned.

QUALIFICATIONS

Education & Licensing

High school diploma or GED required.  State certification or licensing in statutory leaves is preferred or may be required based on state regulations.

Experience
Two (2) years of related experience or equivalent combination of education and experience required. One (1) year of office or customer service experience required. One (1) year of benefits or claims management experience preferred.

Skills & Knowledge

Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application proceduresKnowledge of state and federal FMLA regulationsWorking knowledge of medical terminology and duration managementExcellent oral and written communication, including presentation skillsProficient computer skills including working knowledge of Microsoft OfficeAnalytical, interpretive, and critical thinking skillsStrong organizational and multitasking skillsAbility to work in a team environmentAbility to meet or exceed performance competencies as required by programEffective decision-making and negotiation skillsAbility to exercise judgement with limited supervision

WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

Mental: Clear and conceptual thinking ability; excellent judgment 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

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

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.