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Claims Resolution Expert

2 months ago

Chicago, Illinois, United States Sedgwick Full time
About the Role

Sedgwick is seeking a highly skilled Claims Resolution Expert to join our team. As a key member of our Advocacy Coordination Team, you will play a critical role in resolving complex claims and providing exceptional customer service to our clients.

Key Responsibilities
  • Claims Resolution: Actively researches, resolves, and administers escalated inquiries for all lines of business, including but not limited to Family Medical Leave (FMLA), complex paid and unpaid state, military, and company-specific leaves, accommodations, disability and statutory claims.
  • Customer Service: Provides excellent customer service displaying care and empathy to callers regarding claims and executes 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.
  • Claims Analysis: Makes independent claim determinations, based on the information received, to approve complex claims or make a recommendation to team lead to deny claims based on the requirements.
  • Communication: Communicates clearly and professionally 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 by phone, written correspondence and/or claims system.
  • File Management: Ensures claims files are coded correctly and that adequate documentation is in the claim.
  • Medical Review: 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 takes all necessary action to manage claims process to completion.
  • Benefits Administration: Determines benefits due, makes timely and accurate claims payments/approvals and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets.
  • Client Relationships: Maintains professional client relationships and adheres to client specific requirements such as service level expectations, regulatory requirements, and reporting.
Requirements
  • Education: High school diploma or GED required. 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 SMART, SIR, GAIN, or other HR systems preferred. Experience with TAMS, Juris, viaOne express, and mySedgwick preferred for internal candidates.
  • Skills: Knowledge of ERISA regulations, state and federal FMLA, ADAAA, Social Security application procedures, required offsets and deductions, and disability procedures. Working knowledge of medical terminology and duration management. Proficient computer skills including working knowledge of Microsoft Office. Exemplary call handling and de-escalation skills. Excellent interpersonal communication skills, oral and written. Analytical, interpretive, and critical thinking skills. Effective decision-making. Ability to manage ambiguity. Strong organizational and multitasking skills. Ability to exercise judgement autonomously within established procedures. Ability to work in a team environment. Ability to meet or exceed performance competencies as required by program.
Work Environment

Required to adhere to a set schedule with established break times. 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