Disability Clinical Specialist

Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive.

A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.

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Disability Clinical Specialist

PRIMARY PURPOSE : Performs standard clinical evaluations on claims that require additional review based on medical condition, client requirement, and/or complexity. Consults with providers and employees by providing case direction and ensures medical information substantiates the need for employee absence from work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

Performs standard clinical reviews of referred medical claims based on client requirements to ensure accurate and sufficient information is received by employees and providers to support the claim request and documents decision rationale.
Completes medical review of all claims by reviewing medical documentation received and applying practical clinical knowledge to ensure information substantiates disability and to interpret the impact the condition has on the ability to perform job functions.
Communicates clearly and professionally, on the phone and/or in writing with employee and/or providers to discuss employee’s clinical status, progress, and work status.
Provides clear and appropriate follow-up recommendations for ongoing medical management of claims; ensures appropriate recommendations are made on claims.
Consistently achieves appropriate quality audit scores.
Acts as clinical resource to claims examiners to provide guidance on the medical management of claims including comprehension of medical terminology and substantiating claim decisions.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

Acts as a backup for key disability claims on an ad hoc basis.
Performs other duties as assigned.
Travels as required.

QUALIFICATIONS

Education & Licensing
Bachelor's degree or equivalent preferred. Current RN, LVN, CRC, COHN CVE, LPC and/or LCSW Licenses required. Current license, registration and/or professional designations as required within the jurisdiction. Clinical expertise must be kept current by acquisition of the necessary CEUs to maintain licenses and designations.

Experience
Four (4) years of related experience or equivalent combination of experience and education required to include experience in a direct medical/psychological setting or physical industrial medicine and previous insurance or related experience.

Skills & Knowledge

Knowledge of current medical practices in health care management in a variety of areas (including, but not limited to, orthopedics, general medicine for acute and chronic conditions, general surgery, mental health, obstetrics, oncology, and physical and occupational rehabilitation)
Excellent oral and written communication, including presentation skills
Proficient computer skills including working knowledge of Microsoft Office
Analytical and interpretive skills
Strong organizational and multitasking skills
Excellent interpersonal skills
Ability to exercise judgement and critical thinking skills
Ability to work in a team environment
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: Ability to sit at a desk for extended periods while operating a computer and phone system. 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.

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Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.