Disability Representative Sr

PRIMARY PURPOSE

Provides expert-level disability case management and handles complex claim determinations through thoughtful review of medical documentation and accurate interpretation of disability plan provisions.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

• Independently evaluates and determines eligibility for complex disability claims or provides well-supported recommendations for denial in accordance with plan provisions.
• Reviews and analyzes detailed medical documentation (e.g., attending physician statements, office notes, operative reports) to assess disability status as defined by the plan.
• Manages highly complex claims, including those involving comorbid conditions, concurrent benefits, and ADA accommodation considerations.
• Leverages clinical resources (e.g., duration guidelines, in-house clinicians) to support accurate and consistent claim assessments.
• Calculates benefits due in alignment with disability plans, ensuring accurate and timely payments, adjustments, and application of offsets (e.g., Workers’ Compensation, SSDI).
• Communicates clearly with claimants regarding documentation requirements, timelines, claim status, and benefit details through phone, written correspondence, and system updates.
• PARTNERS WITH HEALTHCARE PROVIDERS TO SET CLEAR EXPECTATIONS AND SUPPORT TIMELY, SAFE RETURN-TO-WORK OUTCOMES.
• Maintains consistent and transparent communication with claimants, clients, and stakeholders throughout the claims process.
• COORDINATES AND OVERSEES INVESTIGATIVE ACTIVITIES, ENSUREING ACCURACY AND APPROPRIATENESS WHILE CONDUCTING THOROUGH REVIEWS OF CONTESTED CLAIMS.
• EVALUATES THE NEED FOR AND COORDINATES REFERRALS TO EXTERNAL VENDORS, INCLUDING PHYSICIAN ADVISORS, INDEPENDENT MEDICAL EVALUATIONS (IMEs), FUNCTIONAL CAPACITY EVALUATIONS, AND SURVEILLANCE.
• COLLABORATES WITH EMPLOYERS AND PROVIDERS TO NEGOTIATE AND FACILITATE RETURN-TO-WORK SOLUTIONS, WITH OR WITHOUT REASONABLE ACCOMMODATIONS.
• ESCALATES CASES TO TEAM LEAD OR CLINICAL CASE MANAGEMENT FOR ADDITIONAL REVIEW WHEN APPROPRIATE.
• BUILDS AND MAINTAINS STRONG CLIENT RELATIONSHIPS WHILE DELIVERING A HIGH LEVEL OF CUSTOMER SERVICE.
• MEETS OR EXCEEDS ORGANIZATIONAL QUALITY STANDARDS AND PERFORMANCE EXPECTATIONS.

ADDITIONAL FUNCTIONS AND RESPONSIBILITIES

• PERFORMS OTHER DUTIES AS ASSIGNED TO SUPPORT TEAM AND BUSINESS OBJECTIVES.