Senior Disability Representative

Role Overview

• Provides disability case management and complex 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 including comorbidities, concurrent plans, and complex ADA accommodations
• Coordinates investigative efforts, thoroughly reviews contested claims, negotiates return to work with or without job accommodations, and evaluates and arranges appropriate referral of claims to outside vendors
• Makes independent claim determinations, based on the information received, to approve complex disability claims or makes a recommendation to team lead to deny claims based on the disability plan
• Reviews and analyzes complex medical information (i.e. attending physician statements, office notes, operative reports, etc.) to determine if the claimant is disabled as defined by the disability plan
• Oversees additional facets of complex claims including but not limited to comorbidities, concurrent plans, complex ADA accommodations, and claims outside of typical guidelines.
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians), as needed
• Determines benefits due pursuant to a disability plan, makes timely claims payments/approvals 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 complex 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 to team lead and clinical case management for additional review when appropriate
• Maintains professional client relationships and provides excellent customer service
• Meets the organization’s quality program(s) minimum requirements

Requirements

• High School diploma or GED required
• Bachelor's degree from an accredited university or college preferred
• State certification or licensing in statutory leaves preferred or may be required based on state regulations
• Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred
• Knowledge of ERISA regulations, required offsets and deductions, disability duration and medical management practices and Social Security application procedures
• Knowledge of state and federal FMLA regulations
• Working knowledge of medical terminology and duration management
• Excellent oral and written communication, including presentation skills
• Proficient computer skills including working knowledge of Microsoft Office
• Analytical, interpretive, and critical thinking skills
• Ability to manage ambiguity
• Strong organizational and multitasking skills
• Ability to work in a team environment
• Ability to meet or exceed performance competencies as required by program
• Effective decision-making and negotiation skills
• Ability to exercise judgement autonomously within established procedures.

Benefits

• hybrid work arrangement
• caring culture
• work-life balance