Job Description
By joining Sedgwick , you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance 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 Act
