Senior Claims Representative
Location: Eden Prairie
Posted on: May 8, 2022
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Senior Claims Representative
IF YOU CARE, THERE'S A PLACE FOR YOU HEREFor a career path that is
both challenging and rewarding, join Sedgwick's talented team of
27,000 colleagues around the globe. Sedgwick is a leading provider
of technology-enabled risk, benefits and integrated business
solutions. Taking care of people is at the heart of everything we
do. Millions of people and organizations count on Sedgwick each
year to take care of their needs when they face a major life event
or something unexpected happens. Whether they have a workplace
injury, suffer property or financial loss or damage from a natural
or manmade disaster, are involved in an auto or other type of
accident, or need time away from work for the birth of a child or
another medical situation, we are here to provide compassionate
care and expert guidance. Our clients depend on our talented
colleagues to take care of their most valuable assets-their
employees, their customers and their property. At Sedgwick, caring
counts -. Join our team of creative and caring people of all
backgrounds, and help us make a difference in the lives of
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
- 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
- Maintains professional client relationships.ADDITIONAL
FUNCTIONS and RESPONSIBILITIES
- Performs other duties as assigned.
- Supports the organization's quality
Education & 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
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
- Excellent oral and written communication, including
- 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 CompetenciesWORK
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 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 and a Drug-Free
Keywords: Sedgwick, Eden Prairie , Senior Claims Representative, Other , Eden Prairie, Minnesota
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