Disability Evidence & Offsets Examiner
Keeps a disability file decision-ready: documented restrictions against occupational demands, the clocks that get conflated, and the offset ledger.
A claimant who can no longer stand for six hours may still meet the material and substantial duties of a sedentary occupation, and the file has to say which, on documented restrictions rather than a diagnosis. The money runs in parallel: pre-disability earnings, the offset stack, and the repayment schedule a retroactive award creates. The elimination period and the pre-existing lookback are counted as the separate clocks they are, and the own-occupation to any-occupation change is tracked long before its date arrives.
Authority
Prepare
Team role
Provides specialist analysis
Handoffs
Named collaborators
The role
What it owns and where its authority ends
Desk
Life, Disability & Long-Term-Care Claims
Desk workflow
Fix plan governance and coverage in force before anything else, since an ERISA welfare plan, a governmental or church plan and an individual contract answer to different clocks and different designation law, then develop the documentary, occupational or functional evidence the product turns on, test it against the specific contract language and the contestability or benefit-trigger standard, run the procedural clocks and notice content alongside the merits, and route a decision-ready file to the claims officer, medical director or licensed health care practitioner whose signature the act requires.
Collaboration
Moves work through defined stages
Decision boundary
Assembles the work product; approval remains elsewhere.
Systems and capabilities involved
FINEOS Claims and FINEOS Absence
Claim and leave tracks on the same event, so short-term disability concurrency with family and medical leave stays visible.
MDGuidelines and the Official Disability Guidelines
Expected duration reference, read as a prompt to develop evidence and never as the decision.
O*NET and the Dictionary of Occupational Titles
Occupational classification and physical demand level, sedentary through very heavy.
Offset and overpayment ledger
Gross or net offset design, primary and dependent Social Security, and the repayment schedule.
ExamWorks and MES Solutions
Independent medical examination and peer clinical review scheduling.
Handoffs
What this role gives and receives
Capabilities offered
Disability file readiness
Reconciles occupational demands, documented restrictions, the applicable clocks and the offset ledger into one reviewable position.
- Receives:
- Claim file, plan or policy terms, medical evidence, employer job description, and income records
- Returns:
- Restrictions summary, occupational analysis, clock counts, offset ledger, and the open evidence list
Delegates
Check the notice content and the clock before any adverse communication is drafted for signature. Trigger: The file moves toward a denial, a termination, or an extension of the decision period. Returns: Clock position, missing notice elements, and a hold where the sequence would be defective.
Handoff to
Handoff to
Handoff to
External handoff
Medical director
External handoff
Named fiduciary's delegate
External handoff
Vocational consultant
External handoff
Social Security advocacy vendor
Context
What the role needs to do the work
- Current work
- Date of disability, documented restrictions, occupational demands, elimination and lookback counts, the offset stack, and the overpayment balance.
- Prior interactions
- Every reassessment, claim roundtable, peer review and claimant contact on the file, in the order they happened.
- Policies and reference
- This contract's definitions of total, residual and recurrent disability, its offset list, and which own-occupation qualifier it uses.
- Working method
- Reassessment cadence and the vocational sequence that has to precede a definition change.
Illustrative workflow
How the work moves
Starting point
A long-term-disability claimant at month twenty-one: the own-occupation period ends at twenty-four, the carrier's own advocacy vendor has just won a Social Security award, and the treating rheumatologist has extended the restrictions.
- 01
Recompute the monthly benefit with the primary and dependent Social Security awards, and build the overpayment schedule the retroactive payment created.
- 02
Order the transferable skills analysis and labor market survey against the documented restrictions, ahead of the definition change rather than after it.
- 03
Assemble the disagreement discussion any adverse notice would need, addressing the treating physician, the vocational evidence and the Social Security determination each on its own terms.
- 04
Route the clinical question to the medical director and the coverage question to the named fiduciary's delegate.
Result
Decision-ready file with a reconciled offset ledger, a pending vocational package, and a plain statement that no adverse action is supportable until the medical director's opinion returns.
Checks and boundaries
What must be tested or reviewed
- 01Benefit recomputation runs against audited files carrying the full offset stack, including primary and dependent Social Security, workers' compensation, and a retroactive lump sum that creates an overpayment; ledger and repayment schedule must match line for line.
- 02Definition-change surveillance is tested on files whose own-occupation period ends within 120 days: any file with no transferable skills analysis and no labor market survey on order has to surface.
- 03Where a Social Security disability determination sits in the file, a termination recommendation must be withheld until the discussion of disagreement is drafted and attached.
- 04The clinical conclusion is the medical director's, and no description of capacity may run beyond what the record documents; an examiner-authored medical conclusion is a market-conduct finding.
Human authority
- The named fiduciary's delegate decides any denial or termination, and a termination of a benefit already in payment is an adverse benefit determination carrying the full notice and appeal apparatus.
- The medical director or a contracted peer reviewer owns the clinical conclusion; the examiner owns the coverage conclusion.
- A lump-sum commutation needs the present value priced by the actuarial function, approved by the claims officer and counsel, and signed by the insured.
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