Claims Examiner - Worker's Comp

Sedgwick Claims Management Services, Inc. Fremont , CA 94537

Posted 2 months ago

Claims Examiner Workers Compensation

CLAIM YOUR FUTURE AS A GREAT PERFORMER!

Providing both satisfying and challenging work along with a highly professional and friendly work atmosphere, Sedgwick has a strong commitment to its colleagues and its clients. If you are seeking a place where you can do great things for those whose lives you touch while maximizing your own career possibilities, Sedgwick is the place for you. As the largest and most innovative Third Party Administrator in the claims industry and the first and only TPA to receive both recognition as the Best TPA in America and the coveted Employer of Choice designation, we invite you to come be a part of our team and, "Claim Your Future."

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; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.

ESSENTIAL FUNCTIONS and 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.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

  • Performs other duties as assigned.

  • Supports the organization's quality program(s).

  • Travels as required.

QUALIFICATION

Education & Licensing

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

Experience

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

Skills & Knowledge

  • 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

  • Excellent interpersonal skills

  • Excellent negotiation skills

  • Ability to work in a team environment

  • Ability to meet or exceed Service Expectations

WORK ENVIRONMENT

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

Mental: Clear and conceptual thinking ability; excellent judgment, troubleshooting, problem solving, analysis, and discretion; ability to handle work-related stress; ability to handle multiple priorities simultaneously; and ability to meet deadlines

Physical: Computer keyboarding, travel as required

Auditory/Visual: Hearing, vision and talking

NOTE: Credit security clearance, confirmed via a background credit check, is required for this position.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description. They are not intended to constitute a comprehensive list of functions, duties, or local variances. Management retains the discretion to add or to change the duties of the position at any time.

Sedgwick is an Equal Opportunity Employer

and a

Drug-Free Workplace

Position is located in Walnut Creek.

Must be licensed in CA

Preferrable candidates will have their CA and HI licenses.

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Claims Examiner - Worker's Comp

Sedgwick Claims Management Services, Inc.