Workers Compensation Claims Examiner
Sedgwick
full-time
Posted on:
Location Type: Hybrid
Location: Concord • California • United States
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Salary
💰 $80,000 - $98,000 per year
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 & Tools
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