Claims Examiner

Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive. 

A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.

Great Place to Work®
Most Loved Workplace® 
Forbes Best-in-State Employer

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.

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. 

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organization's quality program(s).

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

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

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.

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 ($41,211 - $65,000). 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.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.