Claims Examiner – Workers Compensation, Reciprocal Required

Sedgwick

Claims Examiner managing complex workers' compensation claims at Sedgwick in Raleigh, NC. Leveraging expertise to negotiate settlements and manage claims within designated authority.

Posted 4/22/2026full-timeRemote • North Carolina • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

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 claims within designated authority level.
Prepares necessary state filings 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.
Travels as required.

Requirements

What you’ll need

Bachelor's degree from an accredited college or university preferred.
Professional certification as applicable to line of business preferred.
Five (5) years of claims management experience or equivalent combination of education and experience required.
Licensing: Reciprocal 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.

Benefits

Comp & perks

Flexible work schedule.
Referral incentive program.
Opportunity to work in an agile environment.
Career development and promotional growth opportunities.
A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims managementnegotiationreserve calculationcost containmentsubrogationlitigation managementclaims codingmedical management practicesSocial Security application proceduresMedicare application procedures

Soft Skills

oral communicationwritten communicationpresentation skillsanalytical skillsorganizational skillsinterpersonal skillsnegotiation skillsteamworkservice expectations

Certifications

Bachelor's degreeProfessional certificationReciprocal licensing