Medical Claims Examiner

3 weeks ago


Columbus, Ohio, United States Sedgwick Full time

Job Summary

Sedgwick is seeking a highly skilled Medical Claims Processor to join our team. As a Medical Claims Processor, you will be responsible for analyzing and processing complex medical claims, investigating and gathering information to determine the exposure on the claim, and managing claims through well-developed action plans to an appropriate and timely resolution.

Key Responsibilities

  • Analyze and process complex medical claims, including investigating and gathering information to determine the exposure on the claim.
  • Manage claims through well-developed action plans to an appropriate and timely resolution.
  • Conduct or assign full investigation and provide report of investigation pertaining to new events, claims, and legal actions.
  • Negotiate claim settlement up to designated authority level.
  • Calculate and assign timely and appropriate reserves to claims; monitor reserve adequacy throughout claim life.
  • Bring structured settlement proposals as necessary to maximize settlement.
  • Perform coverage analysis and opinion as part of the claim process, including all necessary correspondence.
  • Coordinate legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices.
  • Use appropriate cost containment techniques, including strategic vendor partnerships, to reduce overall claim cost for our clients.
  • Identify and investigate possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost.
  • Represent the company in depositions, mediations, and trial monitoring as needed.
  • Communicate claim activity and processing with the client; ensure claim files are properly documented and claims coding is correct.

Requirements

  • Bachelor of Science in Nursing, Legal Nurse Consultant, Associate in Claims (AIC), Chartered Property and Casualty Underwriter (CPCU), Associate in Risk Management (ARM), Associate in Insurance Claims (AIC), Certified Professional in Health Care Risk Management (CPHRM) preferred.
  • Ten (10) years of complex claims management experience or equivalent combination of education and experience required.
  • In-depth knowledge of appropriate medical malpractice 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 application procedures as applicable to line-of-business.
  • Claims expertise in medical malpractice, errors and omissions, directors and officers, life sciences, and/or cyber liability.
  • PC literate, including Microsoft Office products.
  • Ability to meet or exceed Performance Competencies.
  • Excellent judgment, troubleshooting, problem-solving, analysis, and discretion.
  • Computer keyboarding, travel as required.

Auditory/Visual:

Hearing, vision, and talking.

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.

About Us

Sedgwick is a leading global provider of technology-enabled risk, benefits, and integrated business solutions. We help organizations protect their employees, guide their consumers through the claims process, protect their brand, and minimize business interruptions.



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