Senior Disability Claims Specialist

1 week ago

Kohler, Wisconsin, United States KOHLER Full time

Sr. Disability Claims Examiner

Job Title:

We are seeking a skilled Disability Claims Examiner to join our team at KOHLER.

Key Responsibilities:

  • Evaluate and authorize associate short-term and long-term disability claims, Family Medical Leaves and other Kohler Co. Paid Leaves.
  • Communicate with associates and coordinate the Claim or Leave application process in compliance with both the Summary Plan Descriptions and any local leave law regulations.
  • Update internal documentation and systems, coordinate appropriate payments with Payroll and communicate appropriately with the associate and their manager.
  • Analyze associate disability claims for completeness and eligibility in accordance with the Pay Protection Plan and standard claims processing procedures.
  • Contact attending personal care provider (PCP) as needed to verify disability.
  • Evaluate PCP's basis for disability and compare prescribed work restrictions to functional job requirements for work accommodation.
  • Facilitate medical case review with clinical experts when disability or duration of disability is questionable or exceeds accepted return-to-work guidelines.
  • Approve and authorize assigned claims and determine benefits due pursuant to Pay Protection Plan.
  • Submit required benefit payment information to corporate Payroll.
  • Communicate claim status with associate and manager.
  • Coordinate Pay Protection benefits with pension, Social Security Disability Income (SSDI), Worker's Compensation, state mandated disability benefits, or other benefits.
  • Pursue benefit overpayments as needed.
  • Review claimant's medical return-to-work reports and functional status to determine the associate's eligibility for continued benefit payment or need for claim PCP recertification.
  • Coordinate investigative efforts as necessary, ensuring appropriateness; provides thorough review of contested claims.
  • Evaluate and arrange appropriate referral of claims to outside vendors for independent medical evaluation, functional capacity evaluation or related disability management activities.
  • Train and mentor junior Disability Examiners.
  • Develop, revise and maintain disability benefit administration standard operation procedures (SOP).
  • Provide input for updating Global Benefits Pay Protection Plan when necessary.
  • Offer suggestions on more efficient workflow procedures to supervisor and benefits personnel.
  • Maintain a comprehensive knowledge of the Family Medical Leave Act (FMLA) and related laws in all 50 states to efficiently administer FMLA and related policies.
  • Analyze associate FML Certification of Health Care Provider for completeness and eligibility in accordance with Federal and State family medical leave law.
  • Approve and/or deny FML cases based on relevant medical information.
  • Partner with Labor Relations as needed.
  • Identify questionable patterns or inappropriate requests for FML.
  • Coordinate and organize medical information and ensure that HIPAA and Employee Privacy guidelines are closely monitored and effectively executed.
  • Facilitate Independent Medical Examinations (IME) with a vendor to obtain a second opinion with an independent physician that specializes in the field in question.
  • Provide Parental Leave policies to associates and Human Resources as requested.
  • Provide guidance on other Paid Leave policies (i.e. Parental and Military Leave).
  • Maintain weekly FML reports to the HR Generalists.

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