Sedgwick

Manager

• Sedgwick Field Case Managers work face to face with their injured workers and medical providers to facilitate; though advocacy, progressive medical treatment, and timely return-to-work; while acting as a liaison and providing communication between all involved parties.
• Serve as patient advocate to support, guide and coordinate care for injured workers, families and caregivers as they navigate through the recovery process.
• Assist injured workers in achieving recovery and autonomy through advocacy, communication, education, identification of service resources and service facilitation.
• Identify appropriate providers and facilities throughout the continuum of services, while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the client and the reimbursement source.

RN Field Case Manager

Customer Support

• Handling inbound calls from customers for a variety of queries
• Dealing with multiple clients to deliver the best service we can offer
• Working with suppliers and parts
• Providing excellent customer service at all times

Customer Service Advisor – Fixed Term Contract

Claims Specialist

• Reporting to the Team Leader
• Managing the comprehensive desktop investigation of assigned claims
• Maintaining accurate records based on company standards
• Reviewing and interpreting policy wording to confirm coverage of losses
• Accurately managing the billing for assigned files

Claims Adjuster

• To analyze Workers Compensation claims on behalf of our valued clients to determine benefits due.
• Ensuring ongoing adjudication of claims within service expectations, industry best practices, and specific client service requirements.
• Analyzing and processing claims through well-developed action plans to an appropriate and timely resolution by investigating and gathering information to determine the exposure on the claim.
• Negotiating settlement of claims within designated authority.
• Communicating claim activity and processing with the claimant and the client.
• Reporting claims to the excess carrier and responding to requests of directions in a professional and timely manner.

Workers Compensation Claims Examiner

• Process low level workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
• Develops and coordinates low level workers compensation claims' action plans to resolution, return-to-work efforts, and approves claim payments.
• Approves and processes assigned claims, determines benefits due, and administers action plan pursuant to the claim or client contract.

Claims Representative – Workers Compensation

Pharmacist

• To utilize evidence based tools to evaluate the prescribed medications to ensure patient safety and quality standards are in alignment with best practice standards.
• Performs clinical assessment via information in pharmacy reports and case files; assesses client's situation to include psychosocial needs, cultural implications and support systems in place.
• Evaluates patient drug usage and physician prescribing patterns.
• Evaluates overuse, underuse and misuse of prescribed medications and may recommend testing to determine if drug diversion is present.
• Evaluates need for and recommends alternative treatment.
• Sends letters as needed to prescribing physician(s) and refers to physician advisor as necessary.
• Negotiates appropriate level and intensity of care through use of medical and disability duration guidelines, adhering to quality assurance standards.
• Negotiates changes in pharmacy plan with providers.
• Acts as a resource in consulting with the client, nursing staff and claims examiners regarding pharmacy issues.
• Performs drug utilization reviews through the pharmacy benefit manager or vendor.
• Communicates effectively with claims examiner, client, vendor, supervisor and other parties as needed.
• Maintains client's privacy and confidentiality; promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.

Pharmacy RN

Financial Planning and Analysis

• Directs and manages the Strategic Planning staff; establishes business plan with goals and objectives for the Strategic Planning group.
• Leads managers and related staff in analyzing overall company revenues and expenses as well as revenues and expenses for specific clients.
• Provides leadership and coordination for setting revenue and expense targets for the organization.
• Directs ad hoc reporting assignments; leads ad hoc supporting analysis and results communication with maximum cost savings recommendations.
• Participates in due diligence for acquisitions with upper management for potential acquisitions; coordinates acquisition integrations for the Finance department.

Vice President, Finance

Operations

• Provide leadership, direction, and functional expertise on complex projects
• Develops and executes strategic initiatives and procedures in partnership with claims operations leadership teams
• Establishes and implements priorities, performance goals, and objectives
• Ensures direct reports understand and can articulate client needs
• Leads, inspires, and motivates colleagues to deliver exceptional service outcomes

VP Care Team Operations

Representative

• To process claims and determine benefits due pursuant to a disability plan
• To make timely payments and adjustments for workers compensation, Social Security Disability Income (SSDI), and other disability offsets
• To ensure the ongoing processing of claims

Disability Representative

Client Services Representative

• To manage accounts of multiple client service programs or single large national program; to maintain client, client broker and key vendor relationships; and to manage program procedures and processes that impact customer satisfaction ensuring consistency in process within the account as well as client retention.
• Performs client renewal and Client Service Instruction preparation for assigned clients.
• Coordinates pricing and completes location coding parameters; prepares and distributes stewardship and other reports.
• Coordinates client invoicing, audits and accounts receivable follow-up for assigned clients.
• Educates the client on loss data - drivers of cost impacting assigned programs.
• Coordinate project activity.
• Acts as primary client contact with focus on maintaining and improving overall customer satisfaction.
• Identifies issues that impact customer satisfaction.
• Identifies and solicits cross selling opportunities.
• Coordinates client contracts.

Client Services Manager

• To analyze mid- and higher-level workers compensation claims to determine benefits due.
• To ensure ongoing adjudication of claims within company standards and industry best practices.
• To identify subrogation of claims and negotiate settlements.

Claims Adjuster – Workers Compensation

General

• Analyzes assigned claims and determines benefits due
• Informs claimants of documentation required to process their claim and timeframes
• Manages claim to ensure compliance with plan provisions
• Provides appropriate documentation to LTD Manager for reporting purposes
• Determines need for outside vendors, surveillance and/or independent medical evaluations as required and seeks advice from management, as necessary
• Refers cases to LTD Supervisor, LTD Manager, or Project Manager
• Negotiates settlement of appropriate claims within designated authority level
• Makes claim payments and revisions to benefit amounts
• Communicates status on decisions to client, claimant and supervisor
• Calculates and collects overpayments

LTD Case Specialist

Team Lead

• Develop, implement, and maintain the delivery of world-class service including quality assurance, client services, and workforce management ensuring departmental objectives are met
• Assesses and evaluates current team competencies to develop a baseline of service opportunities
• Leads efforts to refine Service Center measures and tracking systems for program improvements
• Maintains records of training activities, colleague progress, and program effectiveness
• Analyzes and resolves customer service issues
• Supervises a Service Center unit (team) providing leadership, direction, and support and monitors team's daily performance
• Monitors workloads and status; supports colleagues by providing advice on handling complex issues; and identifies and resolves problems and issues
• Works with team leadership to develop, implement, and monitor staff development plans with a focus on overall customer service skills
• Communicates with upper management regarding unit issues and resolutions

Care Team Lead

• Performs initial and ongoing clinical assessment via telephone calls to evaluate the injured worker's injury, medical treatment, psychosocial needs, cultural implications and support systems.
• Effectively communicates and builds relationships with the claims’ examiner, client, injured worker, attorney and supervisor.
• Identifies issues related to delayed recovery and/or return to work and problem solves with a creative thinking approach.
• Negotiates treatment and disability duration with providers through use of medical and disability duration guidelines, adhering to quality.
• Identifies opportunities to expedite care for cost containment and timely medical recovery.
• Provides recommendations for alternate clinical resources to support claim resolution.
• Maintains client's privacy and confidentiality, promotes client safety and advocacy; and adheres to ethical, legal, accreditation and regulatory standards.

Telephonic Case Manager

• Assign utilization review requests.
• Verify and enter data in appropriate system(s).
• Provide general support to clinical staff in a team environment.
• Access, triage and assign cases for utilization review (UR).
• Respond to telephone inquiries proving accurate information and triage as necessary.
• Enter demographics and UR information into claims or clinical management system; maintain data integrity.
• Obtain all necessary information required for UR processing from internal and external sources per policies and procedures.
• Distribute incoming and outgoing correspondence, faxes and mail; upload review documents into paperless system as necessary.
• Support other units as needed.