Key Responsibilities and Required Skills for Disability Claims Specialist

🎯 Role Definition

The Disability Claims Specialist is responsible for end-to-end adjudication and case management of short-term and long-term disability (STD/LTD) claims. This role evaluates medical and vocational evidence, applies plan language and ERISA/FMLA/ADA rules, communicates with claimants and providers, calculates benefits, manages appeals and denials, and ensures claims are processed within SLAs while maintaining a high standard of customer service and regulatory compliance. The ideal candidate combines strong clinical or benefits knowledge with excellent written/verbal communication, analytical decision-making, and a customer-centered approach.

📈 Career Progression

Typical Career Path

Entry Point From:

Claims Processor / Claims Examiner
Benefits Specialist / HR Benefits Coordinator
Medical Records Analyst or Vocational Rehabilitation Assistant

Advancement To:

Senior Disability Claims Specialist / Lead Adjudicator
Disability Claims Supervisor / Manager
Disability Program Manager / ERISA Compliance Specialist
Appeals & Litigation Analyst (Disability)

Lateral Moves:

Leave of Absence Administrator
Benefits Analyst / Total Rewards Specialist
Case Manager / Vocational Rehabilitation Consultant

Core Responsibilities

Primary Functions

Conduct thorough claims adjudication for short-term and long-term disability claims by evaluating policy terms, plan provisions, and ERISA requirements to determine eligibility and benefit entitlement.
Review and interpret complex medical records, physician statements, diagnostic tests, operative reports, and specialist notes to assess functional limitations and correlate clinical findings to policy criteria.
Prepare clear, well-documented benefit determinations—approvals, denials, partial approvals—using plan language, medical evidence, and precedent; document rationale to support audit and appeals processes.
Manage the full claim lifecycle from intake through closure, including initial claim setup, status tracking, payment coordination, and file maintenance to meet SLA and TAT expectations.
Coordinate with claimants, treating providers, employers, case managers, and third-party vendors to obtain timely medical documentation, clarify job demands, and verify return-to-work status.
Execute benefit calculations and payment authorizations accurately, applying offsets, integration with disability or workers’ compensation, and coordination of benefits per policy rules and state regulations.
Lead and participate in vocational assessments and functional capacity reviews in collaboration with vocational rehabilitation vendors to evaluate return-to-work potential and reasonable accommodations.
Investigate potential fraud, misrepresentation, or suspicious claim activity by analyzing inconsistencies, conducting surveillance referrals, and escalating to Special Investigations Units when warranted.
Administer and adjudicate appeals and grievance processes by researching case files, drafting appeal decision letters, and ensuring compliance with internal and external appeal timelines.
Apply federal and state leave laws (FMLA/ADA), Social Security Administration (SSA) guidelines, and Medicare/Medicaid coordination when handling benefit entitlement and offsets.
Document and maintain accurate claim records within the claims management system (e.g., Guidewire, Duck Creek, Oracle Claims, or proprietary platforms) and ensure data integrity for reporting and audits.
Communicate empathetically, clearly, and professionally with claimants and family members to explain decisions, next steps, and available resources while managing expectations.
Escalate complex coverage questions and novel legal issues to legal, compliance, or ERISA subject matter experts; implement guidance and precedent into adjudication practices.
Conduct periodic claim file reviews and utilization review follow-ups to validate ongoing disability status and adjust benefit payments when recovery or return-to-work occurs.
Coordinate with payroll, benefits, and HR teams to reconcile leave balances, COBRA/benefits continuation, and employment status changes that impact claim eligibility or benefit amounts.
Participate in multidisciplinary case reviews and claim strategy meetings to align on high-dollar or long-duration claims, complex medical conditions, or litigation risks.
Create and deliver comprehensive decision letters, correspondence, and claimant-facing documentation that meets regulatory and company standards for clarity and legal sufficiency.
Monitor and report on claim volumes, aging, trends, and KPIs to leadership; recommend process improvements and staffing adjustments to meet service-level objectives.
Support subpoena responses and litigation hold processes for claims in dispute, including preparing redacted medical records and claim chronology for legal review.
Train and mentor junior claims staff on adjudication standards, system use, documentation best practices, and customer service expectations to improve overall team competency.
Maintain current knowledge of medical terminology, ICD-10/CPT coding basics, clinical guidelines, and industry best practices to enhance decision quality and reduce appeals.
Work with data analytics and quality assurance teams to support ad-hoc reporting, root-cause analysis, and continuous improvement projects focused on claims accuracy and turnaround time.

Secondary Functions

Assist in development and maintenance of standard operating procedures, desk guides, and knowledgebase articles to ensure consistent adjudication practices.
Participate in cross-functional projects such as system implementations, claims workflow optimization, and vendor performance evaluations.
Support periodic internal and external audits by preparing documentation, responding to data requests, and implementing corrective actions.
Provide subject-matter expertise for training programs, new-hire onboarding, and competency assessments to elevate team performance.
Contribute to policy interpretation initiatives and benefits communications to HR partners and plan sponsors, clarifying eligibility and coverage nuances.
Support ad-hoc reporting and analytics requests to provide insights into claims trends, cost drivers, and program health to stakeholders.
Engage in customer service quality reviews, call monitoring, and claimant satisfaction initiatives to continuously improve the claimant experience.
Maintain up-to-date continuing education and certification requirements to preserve professional credentials and regulatory compliance.

Required Skills & Competencies

Hard Skills (Technical)

Claims adjudication for short-term disability (STD) and long-term disability (LTD) with demonstrated experience applying plan language and ERISA rules.
Medical records review and clinical documentation analysis, including familiarity with ICD-10 and CPT coding and common clinical terminology.
Knowledge of federal and state leave laws: FMLA, ADA accommodation basics, and how they interact with disability benefits.
Experience with claims management systems (e.g., Guidewire, Duck Creek, Oracle Claims, ClaimsXpress) and strong data entry/documentation skills.
Benefit calculation and integration expertise, including coordination of benefits, offsets, overpayments, and return-to-work adjustments.
Appeals management, grievance adjudication, and experience drafting legally defensible denial and appeal letters.
Functional capacity assessment and vocational analysis experience or ability to interpret vocational reports and job descriptions.
Familiarity with SSA disability processes, vocational rehabilitation programs, and Medicare/Medicaid coordination as applicable.
Proficiency in MS Excel for reporting, pivot tables, and trend analysis; experience with SQL or BI tools (Power BI/Tableau) is a plus.
Experience supporting subpoenas, litigation requests, and working with legal/compliance teams to prepare claim documentation.
Fraud identification and referral processes, including experience working with Special Investigation Units (SIU).
Knowledge of quality assurance standards for claims handling and experience participating in audit remediation projects.

Soft Skills

Strong written and verbal communication skills for claimant correspondence, provider outreach, and cross-functional collaboration.
Empathy and customer-centric mindset to handle sensitive conversations and maintain claimant trust.
Analytical thinking and sound judgment to balance clinical evidence, policy interpretation, and claimant circumstances.
Attention to detail and accuracy in documentation, calculation, and regulatory compliance.
Time management and prioritization skills to manage high caseloads while meeting SLAs and TAT goals.
Problem-solving and escalation judgment to identify complex cases that require SME or legal review.
Collaboration and stakeholder management to work effectively with vendors, HR partners, and clinical teams.
Resilience and stress management when handling emotional claimant interactions and high-volume periods.
Training and mentoring aptitude to develop junior team members and share best practices.
Continuous improvement orientation with a bias for process optimization and operational excellence.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED required; Associate's degree in a related field often accepted with relevant experience.

Preferred Education:

Bachelor’s degree in Nursing, Health Administration, Public Health, Kinesiology, Human Resources, Insurance, or a related field preferred.

Relevant Fields of Study:

Nursing (RN/LPN clinical background)
Health Administration / Public Health
Vocational Rehabilitation / Kinesiology
Human Resources / Business Administration
Insurance / Risk Management

Experience Requirements

Typical Experience Range:

2 to 7 years of progressive experience in disability claims adjudication, benefits administration, or related clinical/insurance roles.

Preferred:

3+ years adjudicating STD and LTD claims, including appeals and ERISA-governed plan experience.
Prior experience with FMLA administration, vocational assessments, and benefits calculation.
Experience in a high-volume claims environment, working with electronic claims systems and meeting SLA/TAT objectives.

Certifications (preferred): Certified Disability Management Specialist (CDMS), Registered Health Information Technician (RHIT), licensed adjuster (state-specific), or claims adjudication/benefits-related professional certification.