Workers Compensation Claims Examiner

4 days ago

San Diego, California, United States Sedgwick Full time
About the Role

We are seeking a highly skilled Workers Compensation Claims Examiner to join our team at Sedgwick. As a key member of our claims team, you will be responsible for analyzing complex workers' compensation claims, determining benefits due, and ensuring timely and cost-effective claims resolution.

Key Responsibilities
  • Analyze and process complex workers' compensation claims, investigating and gathering information to determine exposure and develop action plans for resolution.
  • Negotiate settlements within designated authority levels and calculate and assign timely and appropriate reserves to claims.
  • Calculate and pay benefits due, approve and make timely claim payments and adjustments, and settle claims within designated authority levels.
  • Prepare necessary state filings within statutory limits and manage the litigation process to ensure timely and cost-effective claims resolution.
  • Coordinate vendor referrals for additional investigation and/or litigation management and use 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 and respond to requests for directions in a professional and timely manner.
  • Communicate claim activity and processing with the claimant and client, maintaining professional client relationships.
  • 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 California Workers Compensation claims management experience or equivalent combination of education and experience required.
  • Professional certification as applicable to line of business preferred.
  • 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.
About Sedgwick

Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. We are committed to doing the right thing and taking care of our people, our clients, and our communities. Our team is passionate about delivering exceptional service and making a positive impact on the world.

We offer a comprehensive benefits package, including medical, dental, vision, 401(k), and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. We are an equal opportunity employer and a drug-free workplace.

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