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Sedgwick · 17 hours ago

Claims Examiner - Workers Compensation

United States

Full-time

Remote

Senior Level

$90K/yr - $100K/yr

5+ years exp

Sedgwick is a leading company recognized for its workplace culture and commitment to employee growth. They are seeking a Claims Examiner - Workers Compensation to analyze and manage complex workers' compensation claims, ensuring timely adjudication and negotiation of settlements while maintaining professional client relationships.

BankingInsuranceRisk Management

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 clams within designated authority level

Prepares necessary state fillings 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 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

Claims managementInsurance principlesNegotiation skillsAnalytical skillsMicrosoft OfficeCommunication skillsOrganizational skillsInterpersonal skillsTeamwork

Required

Bachelor's degree from an accredited college or university 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