Disability Representative Sr

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.

• 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.

• 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