Claims Examiner - Workers Comp

PRIMARY PURPOSE : To analyze complex or technically difficult workers compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; and to ensure ongoing adjudication of claims within company standards and industry best practices or client specific requirements.

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Analyzes and processes complex or technically difficult claims by investigating and gathering information to assist employer in determining their position on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
• Works to move claim towards appropriate claim closure which may include referral for settlement evaluation.
• Monitors reserve adequacy throughout the life of the claim if applicable.
• Monitors and reviews benefits due and payment calculations ensuring accuracy.
• Prepares necessary state filings within statutory limits.
• Follows best practice standards in contested claims including outside legal representation.
• Coordinates vendor referrals for additional investigation and/or litigation management.
• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
• Participates in claim recoveries including, but not limited to: subrogation, Second Injury Fund recoveries, and Social Security offsets.
• Communicates claim action/processing with appropriate parties including, but not limited to: claimant, client, state agency, managed care organization and appropriate medical contact.
• Ensures claims files are properly documented and claims coding is correct.
• Maintains professional client relationships.
• Coordinates actuarial/settlement issues impacting employers with rate and settlement departments.
Assesses policy level status of clients; works in coordination with clients' service expectations and assigned service personnel.

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QUALIFICATIONS

Education & Licensing

Bachelor's degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line-of-business preferred.

Experience

Four (4) years claims management experience or equivalent combination of education and experience required.

Skills & Knowledge

• In-depth line-of-business knowledge of appropriate insurance principles and laws, recoveries offsets and deductions, and cost containment principles
• Excellent oral and written communication skills, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Good interpersonal skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies
• Supports the organization's quality program(s).
Performs other duties as assigned.

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WORK ENVIRONMENT

When applicable and appropriate, consideration will be given to reasonable accommodations.

TAKING CARE OF YOU BY

• We offer a diverse and comprehensive benefits package including:
  • Three Medical, and two dental plans to choose from.
  • Tuition reimbursement eligible.
  • 401K plan that matches 50% on every $ you put in up to the first 6% you save.
  • 4 weeks PTO your first full year.

NEXT STEPS

If your application is selected to advance to the next round, a recruiter will be in touch.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $47,000 - $50,000. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.