Claims Examiner

5 days ago


Roseville, California, United States Sedgwick Full time
About the Role

Sedgwick is a leading provider of technology-enabled risk, benefits, and integrated business solutions. We are seeking a highly skilled Claims Examiner to join our team of talented professionals.

Key Responsibilities
  • Analyze mid- and higher-level general liability claims to determine benefits due
  • Ensure ongoing adjudication of claims within company standards and industry best practices
  • Identify subrogation of claims and negotiate settlements
  • Manage mid-level general liability claims by gathering information to determine liability exposure
  • Assign reserve values to claims, make claims payments as necessary, and settle claims up to designated authority level
  • Assess liability and resolve claims within evaluation
  • Approve and process assigned claims, determine benefits due, and manage action plan pursuant to the claim or client contract
  • Manage subrogation of claims and negotiate settlements
  • Communicate claim action with claimant and client
  • Ensure claim files are properly documented and claims coding is correct
  • May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review
  • Maintain professional client relationships
Requirements
  • Bachelor's degree from an accredited college or university preferred
  • Four (4) 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
  • 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
Work Environment

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



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