Sr. Clams Representative - DisabilitySedgwick, Dubuque, IA Dubuque, IA
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Our goal is to make Sedgwick CMS a place where great people can do great things for our clients. This commitment is evidenced by our colleague development program and supported by our multi-dimensional learning resources.
We invest in the education of our colleagues by providing training and learning resources that focus on our culture, procedures, systems and performance expectations. We evaluate the educational needs of our colleagues through performance discussions and evaluations. These needs are filled either through Sedgwick CMS University and through industry certification programs and other external educational resources . Sedgwick CMS University curriculum offerings take colleagues from orientation to technical training to supervisory and managerial development. Through Sedgwick CMS University, we provide our colleagues continuous development of professional skills and the ability to deliver quality service to our clients.
We offer a required colleague orientation program that allows us to verify and document the training provided to new colleagues. This program is called Personal Responsibility in Developing Excellence (PRIDE) and is the first component of our comprehensive career development process. This program introduces and orients new and transitioning colleagues to our company and to their new position. PRIDE will take colleagues through the first 90 days of their new position. Objectives of this program focus on providing colleagues an increased awareness of who we are, where we are going, and how they can help us get there.
Career path options are identified through an ongoing process of discussion and collaboration between colleagues and their managers. On an ongoing basis, our managers counsel colleagues regarding their career path, new opportunities, and additional training and development requirements to help them reach their individual goals.
Disability Representative Sr
PRIMARY 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 for physician advisor reviews, surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
- Negotiates return to work with our without job accommodations via the claimants physician and employer.
- Refers cases as appropriate to supervisor and management.
- Maintains professional client relationships.
ADDITIONAL FUNCTIONS and RESPONSIBILITIES
- Performs other duties as assigned.
- Supports the organization's quality program(s).
Education & Licensing
Bachelor's degree from an accredited university or college preferred.
Three (3) years of benefits or disability 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
- 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
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: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking
NOTE: 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.
Sedgwick is an Equal Opportunity Employer
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Employee Retirement Income Security Act
Social Security Disability Insurance
Paid Sick Leave
|Years of Experience||2-5 Years|