Workers Compensation Claims Examiner

4 weeks ago


Roseville, California, United States Sedgwick Full time

Job Summary

Sedgwick is seeking a skilled Workers Compensation Claims Examiner to join our team. As a Claims Examiner, you will be responsible for analyzing complex workers' compensation claims to determine benefits due. Your expertise will be essential in managing claims through well-developed action plans to achieve timely and cost-effective resolutions.

Key Responsibilities

  • Analyze complex or technically difficult workers' compensation claims to determine benefits due
  • Work with high exposure claims involving litigation and rehabilitation
  • Ensure ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements
  • Identify subrogation of claims and negotiate settlements
  • Manage claims through well-developed action plans to achieve timely and cost-effective resolutions
  • Negotiate settlement of claims within designated authority
  • Calculate and assign timely and appropriate reserves to claims
  • Manage reserve adequacy throughout the life of the claim
  • Approve and make timely claim payments and adjustments
  • Manage the litigation process
  • Ensure timely and cost-effective claims resolution
  • Coordinate vendor referrals for additional investigation and/or litigation management
  • Use appropriate cost containment techniques to reduce overall cost of claims for our clients
  • Manage claim recoveries, including subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets
  • Report claims to the excess carrier
  • Communicate claim activity and processing with the claimant and the client
  • Ensure claim files are properly documented and claims coding is correct

Requirements

  • 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
  • PC literate, including Microsoft Office products
  • Excellent judgment, troubleshooting, problem-solving, analysis, and discretion
  • Computer keyboarding, travel as required

Auditory/Visual:

Hearing, vision, and talking

Security Clearance:

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

Benefits:

A comprehensive benefits package is offered, including medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits



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