Disability Case Manager / Disability Claims Specialist

Job Title: Disability Case Manager / Disability Claims Specialist

📍 Overview

We are seeking a detail-oriented and analytical Disability Case Manager to manage end-to-end disability claims, including adjudication, benefit determination, and case management. This role involves reviewing medical documentation, interpreting disability plans, and collaborating with clinical and vocational resources to support claimants and facilitate return-to-work outcomes.

🧩 Key Responsibilities

• Manage disability claims lifecycle from intake through adjudication, payment, and closure.
• Review and analyze medical documentation (diagnostic tests, physician notes, operative reports, etc.) to determine eligibility based on plan definitions.
• Perform claims adjudication by interpreting disability plans and determining benefits due.
• Ensure timely and accurate claim payments, adjustments, and approvals.
• Handle claims related to Short-Term Disability (STD), Workers’ Compensation, State Disability, and applicable offsets.
• Initiate outreach to claimants, physicians, and employers to obtain missing or additional documentation.
• Collaborate with clinical, vocational, and rehabilitation teams to evaluate disability status and support return-to-work (RTW) strategies.
• Utilize clinical guidelines and internal resources (e.g., duration guidelines, in-house clinicians) for case assessment.
• Communicate effectively with claimants and clients via phone and written correspondence, setting clear expectations throughout the claims process.
• Manage daily workload, ensuring adherence to SLAs, quality standards, and regulatory requirements.
• Handle escalations and peer reviews, ensuring accuracy and compliance.
• Identify opportunities for process improvement and contribute to service excellence initiatives.
• Participate in special projects and additional responsibilities as assigned.

🛠️ Required Skills & Qualifications

• Bachelor’s degree or equivalent work experience (preferably in healthcare, insurance, or a related field).
• Proven experience in disability claims management or adjudication.
• Strong knowledge of Short-Term Disability (STD), Long-Term Disability (LTD), and Workers’ Compensation.
• Ability to review and interpret medical records and clinical information.
• Familiarity with claims systems and case management tools.
• Excellent analytical, decision-making, and problem-solving skills.
• Strong communication and stakeholder management abilities.
• Ability to manage multiple claims and prioritize workload effectively.
• Knowledge of regulatory guidelines and insurance practices is preferred.