Disability Specialist III

Continuing double-digit revenue growth rates and progressive employment practices make Sedgwick Claims Management Services the place where great people can do great things for clients while maximizing their career possibilities. We have earned a reputation for innovation, quality, sustained growth, financial stability and a colleague-friendly work environment. We are proud to have been voted the Best TPA in America for 2005 and 2006, and the first and only Third Party Administrator to receive the coveted Employer of Choice designation. Come be a part of our team and "Claim Your Future."

PRIMARY PURPOSE: To analyze reported claims, determine benefits due and make timely payments and adjustments; to medically manage disability claims; to coordinate investigative efforts and to thoroughly review contested claims; to evaluate and arrange appropriate referral of claims to outside vendors; and to negotiate settlement of claims up to the designated authority level.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

1. Analyzes, approves and authorizes assigned claims and determines benefits due pursuant to a disability plan.
2. Determines benefits due, makes timely claims payments and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
3. Medically manages disability claims ensuring compliance with duration control guidelines and plan provisions.
4. Communicates clearly with claimant and client on all aspects of claims process either by phone and/or written correspondence.
5. 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.
6. Coordinates investigative efforts ensuring appropriateness; provides thorough review of contested claims.
7. Evaluates and arranges appropriate referral of claims to outside vendors for surveillance, independent medical evaluation, functional capability evaluation, and/or related disability activities.
8. Refers cases as appropriate to supervisor and management.
9. Negotiates settlement of claims up to designated authority level.
10. Maintains professional client relationships.
11. Maintains a quality assurance program to support the total performance management initiative and the consistent delivery of quality claims service.

QUALIFICATIONS

Education & Licensing
Baccalaureate degree from an accredited college or university in nursing, social work or vocational rehabilitation is preferred. At least one of the following licenses is required: RN, LVN, CRC, COHN, CVE, LPC or LCSW.

Experience
Three (3) years benefits or disability claims management experience required.

Skills & Knowledg

• 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

WORK ENVIRONMENT

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 CMS is an Equal Opportunity Employer

and a

Drug-Free Workplace