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Company

Original Job Post

Sedgwick · 3 days ago

Claims Examiner

Florida, United States

Full-time

Onsite

Mid, Senior Level

5+ years exp

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Responsibilities

Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.

Negotiates settlement of claims within designated authority.

Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.

Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.

Prepares necessary state filings within statutory limits.

Manages the litigation process; ensures timely and cost-effective claims resolution.

Coordinates vendor referrals for additional investigation and/or litigation management.

Uses appropriate cost containment techniques including strategic vendor partnerships to reduce the overall cost of claims for our clients.

Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.

Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.

Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.

Ensures claim files are properly documented and claims coding is correct.

Refers cases as appropriate to supervisor and management.

Performs other duties as assigned.

Supports the organization's quality program(s).

Travels as required.

Qualification

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Claims managementInsurance principlesCost containmentMedical managementSocial SecurityMedicare applicationPC literacyMicrosoft OfficeService expectationsCommunicationAnalyticalOrganizationalInterpersonalNegotiationTeamwork

Required

Bachelor's degree from an accredited college or university preferred

Professional certification as applicable to line of business preferred

Five (5) years of claims management experience or equivalent combination of education and experience required

Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business

Excellent oral and written communication, including presentation skills

PC literate, including Microsoft Office products

Analytical and interpretive skills

Strong organizational skills

Good interpersonal skills

Excellent negotiation skills

Ability to work in a team environment

Ability to meet or exceed Service Expectations