Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive.A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.Great Place to Work®Most Loved Workplace®Forbes Best-in-State EmployerDisability Representative SrOur teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near one of our centers of excellence:Dubuque, IA : 4141 Westmark Drive, Dubuque, IA 52002Cedar Rapids, IA : 333 1st Street SE Ste. 200 Cedar Rapids IA 52401Coralville, IA: 3273 Ridgeway Drive Coralville IA 52241Dublin, OH : 5500 Glendon Court Dublin OH 43016New Albany, OH : 7795 Walton Parkway New Albany, OH 43054Chicago, IL : 175 W. Jackson Blvd. 12th Fl. Chicago IL 60604Indianapolis, IN: 8909 Purdue Road Suite 501 Indianapolis, IN 46268Irving, TX : 2201 W. Royal Lane Suite 125 Irving, TX 75063Memphis, TN : 8125 Sedgwick Way, Memphis TN 38125Southfield, MI : 300 Galleria Officentre Southfield MI 48034Orlando, FL : 12650 Ingenuity Dr Orlando FL 32826Eden Prairie, MN : 11000 Prairie Lakes Drive Eden Prairie, MN 55344PRIMARY PURPOSE : To provide disability case management and claim determinations based on complex 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, thoroughly reviewing contested claims, negotiating return to work with or without job accommodations, and evaluating and arranging appropriate referral of claims to outside vendors.ESSENTIAL FUNCTIONS and RESPONSIBILITIES
Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan.
Reviews and analyzes complex medical information (i.e. diagnostic tests, office notes, operative reports, etc.) 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).
Communicates with the claimants providers to set expectations regarding return to work.
Determines benefits due, makes timely claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.
Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.
Informs claimants of documentation required to process claims, required time frames, payment information and claims status either 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 claimants physician and employer.
Refers cases as appropriate to team lead and clinical case management.
Maintains professional client relationships.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
Performs other duties as assigned.
Supports the organization's quality program(s).
QUALIFICATIONSEducation & LicensingBachelor's degree from an accredited university or college preferred.ExperienceThree (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience required.Skills & Knowledge
Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
Working knowledge of medical terminology and duration management
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytical and interpretive skills
Strong organizational skills
Ability to work in a team environment
Excellent negotiation skills
Ability to meet or exceed Performance Competencies
WORK ENVIRONMENTWhen 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 deadlinesAs required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $20 - $22.50 per hour. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.Physical : Computer keyboarding, travel as requiredAuditory/Visual : Hearing, vision and talkingNOTE : Credit security clearance, confirmed via a background credit check, is required for this position.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.#claimsexaminerSedgwick 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.Taking care of people is at the heart of everything we do. Caring countsSedgwick is a leading global provider of technology-enabled risk, benefits and integrated business solutions. Every day, in every time zone, the most well-known and respected organizations place their trust in us to help their employees regain health and productivity, guide their consumers through the claims process, protect their brand and minimize business interruptions. Our more than 30,000 colleagues across 80 countries embrace our shared purpose and values as they demonstrate what it means to work for an organization committed to doing the right thing – one where caring counts. Watch this video to learn more about us. (https://www.youtube.com/watch?v=ywxedjBGSfA)