Disability Representative Sr

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.

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Sr. Disability Representative

Our teams connect! We collaborate onsite and have a hybrid work arrangement. All candidates must live near our center of excellence:

West Hills, CA : 8521 Fallbrook Ave West Hills, CA 91304

** PRIMARY PURPOSE** :

Provides expert-level disability case management and handles complex claim determinations through thoughtful review of medical documentation and accurate interpretation of disability plan provisions. Responsible for determining benefits eligibility, issuing timely payments and adjustments, and managing claims involving comorbidities, concurrent plans, and ADA accommodations. Coordinates investigative efforts, thoroughly evaluates contested claims, partners with stakeholders to support return-to-work outcomes (with or without accommodations), and facilitates appropriate referrals to external resources and vendors.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Independently evaluates and determines eligibility for complex disability claims or provides well-supported recommendations for denial in accordance with plan provisions.

• Reviews and analyzes detailed medical documentation (e.g., attending physician statements, office notes, operative reports) to assess disability status as defined by the plan.

• Manages highly complex claims, including those involving comorbid conditions, concurrent benefits, and ADA accommodation considerations.

• Leverages clinical resources (e.g., duration guidelines, in-house clinicians) to support accurate and consistent claim assessments.

• Calculates benefits due in alignment with disability plans, ensuring accurate and timely payments, adjustments, and application of offsets (e.g., Workers’ Compensation, SSDI).

• Communicates clearly with claimants regarding documentation requirements, timelines, claim status, and benefit details through phone, written correspondence, and system updates.

• Partners with healthcare providers to set clear expectations and support timely, safe return-to-work outcomes.

• Oversees medical management of claims to ensure compliance with duration guidelines and plan provisions.

• Maintains consistent and transparent communication with claimants, clients, and stakeholders throughout the claims process.

• Coordinates and oversees investigative activities, ensuring accuracy and appropriateness while conducting thorough reviews of contested claims.

• Evaluates the need for and coordinates referrals to external vendors, including physician advisors, independent medical evaluations (IMEs), functional capacity evaluations, and surveillance.

• Collaborates with employers and providers to negotiate and facilitate return-to-work solutions, with or without reasonable accommodations.

• Escalates cases to team lead or clinical case management for additional review when appropriate.

• Builds and maintains strong client relationships while delivering a high level of customer service.

• Meets or exceeds organizational quality standards and performance expectations.

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ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned to support team and business objectives.

QUALIFICATIONS

** Education & Licensing**
High School diploma or GED required. Bachelor's degree from an accredited university or college preferred. State certification or licensing in statutory leaves is preferred or may be required based on state regulations.

Experience
Three (3) years of benefits or disability case/claims management experience or equivalent combination of education and experience preferred.

Skills & Knowledge

• Strong knowledge of ERISA regulations, disability plan provisions, benefit offsets/deductions, and Social Security (SSDI) processes and application procedures

• In-depth understanding of state and federal FMLA regulations and their impact on disability claims management

• Working knowledge of medical terminology, clinical documentation, and disability duration and case management practices

• Excellent verbal and written communication skills, with the ability to clearly convey complex information to diverse audiences, including claimants, providers, and clients

• Proficiency in Microsoft Office Suite and claims management systems, with strong technical aptitude

• Advanced analytical, interpretive, and critical thinking skills with the ability to evaluate complex scenarios and make sound decisions

• Ability to navigate ambiguity and adapt to evolving claim details, regulations, and business needs

• Strong organizational skills with the ability to manage multiple priorities, deadlines, and complex caseloads effectively

• Collaborative team player with the ability to work cross-functionally in a dynamic environment

• Demonstrated ability to meet or exceed performance and quality standards within a structured program

• Strong decision-making and negotiation skills, particularly in return-to-work discussions and claim resolutions

• Ability to exercise independent judgment and discretion while operating within established guidelines and compliance standards

** WORK ENVIRONMENT**
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

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $26.00 - $28.00 USD Hourly . A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align

perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.