Claims Examiner

Sedgwick is seeking a highly skilled Claims Examiner to join our team. As a Claims Examiner, you will play a critical role in analyzing complex workers' compensation claims to determine benefits due, working with high-exposure claims involving litigation and rehabilitation, and ensuring ongoing adjudication of claims within company standards and industry best practices.

• Claims Analysis and Processing: Analyze and process complex or technically difficult claims by investigating and gathering information to assist employers in determining their position on the claim, and manage claims through well-developed action plans to an appropriate and timely resolution.
• Claim Closure and Reserve Management: Work to move claims towards appropriate claim closure, which may include referral for settlement evaluation, and monitor reserve adequacy throughout the life of the claim if applicable.
• Benefits and Payment Calculations: Monitor and review benefits due and payment calculations to ensure accuracy, and prepare necessary state filings within statutory limits.
• Contested Claims and Vendor Management: Follow best practice standards in contested claims, including outside legal representation, and coordinate vendor referrals for additional investigation and/or litigation management.
• Cost Containment and Recovery: Use appropriate cost containment techniques, including strategic vendor partnerships, to reduce overall cost of claims for our clients, and participate in claim recoveries, including subrogation, Second Injury Fund recoveries, and Social Security offsets.
• Communication and Documentation: Communicate claim action/processing with appropriate parties, including claimants, clients, state agencies, managed care organizations, and medical contacts, and ensure claims files are properly documented and claims coding is correct.
• Client Relationships and Actuarial/Settlement Issues: Maintain professional client relationships, coordinate actuarial/settlement issues impacting employers with rate and settlement departments, and assess policy level status of clients to work in coordination with clients' service expectations and assigned service personnel.

• Education and Experience: Bachelor's degree from an accredited college or university preferred, with four (4) years of claims management experience or equivalent combination of education and experience required.
• Skills and Knowledge: In-depth line-of-business knowledge of 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, and ability to meet or exceed Performance Competencies.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace. We offer a comprehensive benefits package, 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.