Disability Representative

Disability Representative

Requirements

• High school diploma or GED required
• Two (2) years of related experience or equivalent combination of education and experience required
• One (1) year of office or customer service experience required
• 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
• 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 with limited supervision

Responsibilities

• Makes claim determinations, based on the information received, to approve routine disability claims or makes a recommendation to team lead to deny claims based on the disability plan
• Reviews and analyzes routine medical information (i.e. attending physical statements, office notes, off work notes, etc.) or consults with a nurse to determine if the claimant is disabled as defined by the disability plan
• Utilizes the appropriate clinical resources in case assessment (i.e. duration guidelines, in-house clinicians) regularly
• Determines benefits due, makes timely claims payments 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 routine 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 as appropriate to team lead and clinical case management to assist with claim determination
• Meets the organization’s quality program(s) minimum requirements
• Maintains professional client relationships and provides excellent customer service

Preferred Qualifications

• One (1) year of benefits or claims management experience preferred