Sr. Disability Claims Examiner

Sr. Disability Claims Examiner

Work Mode: Hybrid

Location: Hybrid - Kohler, WI

Opportunity

The Sr. Disability Claims Examiner is responsible for evaluating and authorizing (or denying) associate short-term and long-term disability claims, Family Medical Leaves and other Kohler Co. Paid Leaves.  The position is also responsible for communication with associates and coordinating the Claim or Leave application process in compliance with both the Summary Plan Descriptions and any local leave law regulations. If a Claim or Leave is approved, the Sr. Disability Claims Examiner then updates internal documentation and systems, coordinates appropriate payments with Payroll and communicates appropriately with the associate and their manager.

Specific Responsibilities

Disability Plan Administration

• 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 (e.g. MDGuidelines or Occupational Disability 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.
• Evaluates and arranges appropriate referral of claims to outside vendors for independent medical evaluation, functional capacity evaluation or related disability management activities.

Train and mentor junior Disability Examiner(s).

• 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 work-flow procedures to supervisor and benefits personnel.

Leave Administration

• 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 denies FML cases based on relevant medical information. Partners with Labor Relations as needed.
• Partner with HR and Labor Relations to identify questionable patterns or inappropriate requests for FML.
• Coordinate and organize medical information and ensures 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).
• Provide and maintain weekly FML reports to the HR Generalists.
• Provide and maintain “view access” to LeaveSource to the HR Generalists.
• Provide and maintain monthly reports from LeaveSource to capture leave trends and totals from all locations.
• Provide other annual reports as needed (i.e. Tax Credit and ACA Compliance report).
• Perform other related duties assigned.