Workers Compensation Claims Examiner
Sedgwick
full-time
Posted on:
Location Type: Hybrid
Location: Concord • California • 🇺🇸 United States
Visit company websiteSalary
💰 $80,000 - $98,000 per year
Job Level
Mid-LevelSenior
About the role
- To analyze complex or technically difficult workers' compensation claims to determine benefits due.
- To work with high exposure claims involving litigation and rehabilitation.
- To ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements.
- To identify subrogation of claims and negotiate settlements.
- Analyzes and processes complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim.
- Manages claims through well-developed action plans to an appropriate and timely resolution.
- Negotiates settlement of claims within designated authority.
- Calculates and assigns timely and appropriate reserves to claims; manages reserve adequacy throughout the life of the claim.
- Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles clams within designated authority level.
- Prepares necessary state fillings within statutory limits.
- Manages the litigation process; ensures timely and cost effective claims resolution.
- Coordinates vendor referrals for additional investigation and/or litigation management.
- Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
- Manages claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
- Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
- Communicates claim activity and processing with the claimant and the client; maintains professional client relationships.
- Ensures claim files are properly documented and claims coding is correct.
- Refers cases as appropriate to supervisor and management.
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.
- 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.
Benefits
- medical, dental, vision
- 401k and matching
- PTO
- disability and life insurance
- employee assistance
- flexible spending or health savings account
- other additional voluntary benefits
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
claims managementworkers' compensation claims analysisnegotiationsubrogationreserve calculationclaims codinglitigation managementcost containment techniquesvendor coordinationstatutory compliance
Soft skills
oral communicationwritten communicationpresentation skillsanalytical skillsorganizational skillsinterpersonal skillsnegotiation skillsteamworkservice expectationsproblem-solving
Certifications
Bachelor's degree