Workforce Absence Care Team Representative
Sedgwick
TN
há 5 dias

PRIMARY PURPOSE

  • To actively research, resolve, and administer escalated inquires for all lines of business including but not limited to FMLA, Accommodations, and disability claims;
  • and to execute technical and jurisdictional requirements for accurate claims processing, benefit review and interpretation of regulations, financial payment processing, and error correction of complex or high exposure claims.

    ESSENTIAL FUNCTIONS and RESPONSIBILITIES

  • Analyzes and authorizes claims and determines benefits due pursuant to a plan.
  • Enters and adjusts payments and evaluates file interface to support payment research and resolution.
  • Communicates clearly with claimant and client on all aspects of the claims process including : claim approval, decision authority level to move the call forward, and issue resolution.
  • Facilitates claim resolution with claimant, human resources managers, treating physician’s office, client, or other callers.
  • Ensures claims files are coded correctly and that adequate documentation is in the claim.
  • 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 plan and take all necessary action to manage claims process to completion.
  • Informs claimants and client of documentation required to process claims, required timeframes, payment information and claims status.
  • Determines benefits due, makes timely claims payments / approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
  • ADDITIONAL FUNCTIONS and RESPONSIBILITIES

  • Performs other duties as assigned.
  • Supports the organization's quality program(s).
  • QUALIFICATIONS

    Education & Licensing

    Bachelor's degree from an accredited college or university preferred.

    Experience

    Three (3) years of related experience or equivalent combination of experience and education required to include two (2) years of disability claims experience.

    Experience with TAMS, Juris, SMART, SIR, viaOne express, GAIN, or other HR system preferred.

    Skills & Knowledge

  • Knowledge of ERISA regulations, FMLA, ADAAA, disability procedures and basic clinical terminology.
  • Excellent oral and written communication skills
  • PC literate, including Microsoft Office products
  • Analytical and interpretive skills
  • Excellent interpersonal skills
  • Strong organizational skills
  • Ability to work in a team environment
  • Ability to meet or exceed Performance Competencies
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