Sedgwick

Claims Specialist

• Processes low level bodily injury liability claims by gathering information to determine liability exposure; assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level.
• Develops and coordinates low level general liability 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.
• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.

Claims Representative – Liability, Bodily Injury, Multi State

• 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.

Workers Compensation Claims Adjuster

Manager

• 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

• Independently handle a capped caseload of workers' compensation claims, from inception to resolution.
• Ensure compliance with New York workers' compensation laws, including timely filing of reports, adherence to benefit payment timelines, and compliance with statutory requirements.
• Negotiate settlements of claims within designated authority to reach claim resolution.
• Provide clear and effective communication with the claimant and client.
• Report claims to the excess carrier and respond to requests of directions in a professional and timely manner.
• Maintain accurate and comprehensive records in the claims management system, documenting all actions, decisions, and correspondence related to each claim.

Workers Compensation Claims Adjuster – NY Jurisdictional Knowledge Required

• 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.

Claims Examiner – Workers Compensation, Public Entity Experience Required

• Attendance and completion of designated claims professional training program.
• Adjusting various levels of workers’ compensation claims under close supervision, which includes: Processing and responding to incoming mail, and other claim-related documents according to status of the claim.
• Communicating effectively with injured workers, insureds/employers, medical providers, attorneys and carrier representatives, primarily through telephonic, video conference and email.
• Thoroughly investigating new and existing claims by gathering relevant information including medical records, employer reports, and witness statements.
• Investigating employer/employee relationships, policy verification, coverage and any potential for subrogation issues or fraud indicators.
• Determining coverage, compensability and appropriate benefits in accordance with jurisdictional guidelines and carrier program requirements.
• Documenting claims files and properly coding claim activity.
• Preparing detailed reports documenting findings and recommendations.
• Administering claim benefits, ensuring state compliance.
• Participating in virtual and/or in-person meetings, claim reviews and business functions as needed.

Claims Representative – Workers Compensation Training Program

• 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 – MD, VA, DC Jurisdictional Experience

• 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.

Claims Examiner – Workers Compensation, Reciprocal Required

Workers Compensation Claims Examiner – CT Jurisdictional Knowledge Required

• Analyze reported lower-level workers compensation claims to determine benefits due.
• Ensure ongoing adjudication of claims within company standards and industry best practices.
• Handle lower-level liability and/or physical damage claims under close supervision.
• Support other claims representatives, examiners, and leads with larger or more complex claims as necessary.
• Process general liability claims determining compensability and benefits due; monitor reserve accuracy, and file necessary documentation with state agency.
• Communicate claim action/processing with claimant, client, and appropriate medical contact.
• Ensure claim files are properly documented and claims coding is correct.
• May process routine payments and prescriptions and status reports for lifetime medical claims and/or defined period medical claims.
• Maintain professional client relationships.

Claims Associate – Liability

• To analyze mid- and higher-level general liability 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.
• Manages mid-level general liability claims by gathering information to determine liability exposure.
• Assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Manages subrogation of claims and negotiates settlements.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• May process complex lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
• Maintains professional client relationships.

Claims Adjuster – Liability, GL and Litigation

• To analyze mid- and higher-level general liability 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.
• Manages mid-level general liability claims by gathering information to determine liability exposure.
• Approves and processes assigned claims, determines benefits due, and manages action plan pursuant to the claim or client contract.
• Communicates claim action with claimant and client.

General Liability Claims Adjuster – Licensure Required

• To process low level workers compensation claims to determine benefits due.
• Ensure ongoing adjudication of claims within company standards and industry best practices.
• Identify subrogation of claims and negotiate settlements with general supervision.
• Processes low level workers compensation claims determining compensability and benefits due on long term indemnity claims.
• Approves and processes assigned claims, determines benefits due and administers action plan pursuant to the claim or client contract.

Workers Compensation Claims Representative

Network Engineer

• To ensure clients and Managed Care Organization’s covered employees are provided information on eligibility, coverage, providers, general procedure instructions, and regulations regarding MCO services;
• To work with MCO provider on physician credentialing, MCO additions and removals, network and problematic issues.
• Works directly with clients, program managers, and MCO covered injured workers to ensure they are provided information on eligibility, coverage, provider identification, general procedure instructions, and regulations regarding Sedgwick CMS (company) MCO’S.
• Works with the company Medical Director and vendor partner(s) on physician identification and credentialing processes, MCO provider additions and removals, MCO network issues; makes recommendations for resolution.
• Contacts providers to verify new workers' compensation patients are being accepted; tracks credentialing of MCO providers.
• Communicates with injured workers relative to the provider pre-designation rules and procedures.
• Maintains MCO matrix as to the status of client's respective MCO.
• Communicates with clients relative to their MCO status.
• Ensures claims management system parameters are set for MCO flags.
• Responds to client and MCO covered injured workers' issues; communicates issues to upper management with solution recommendation as appropriate.

Provider Network Specialist

Business Development Rep

• To expand and enhance the company's top line through diligent relationship building and maintenance with prospective clients across an area.
• To identify and address prospective and existing client opportunities for marketing the company's programs.
• To ensure sales goals, objectives and profit margins are met.
• Identifies, develops and maintains internal and external relationships/partnerships.
• Builds relationships with prospects.
• Facilitates the development of new partnerships and the company; facilitates and remains involved in the implementation process ensuring a smooth transition of new client programs.
• Develops the detailed knowledge of individual prospect operations targeting specific needs which may be opportunities for marketing company programs.
• Ensures the identification of expertise required addressing individual prospect requirements; identifies resources for prospect solicitation and service teams.
• Utilizes the appropriate national resources to facilitate responses and pricing for RFPs, proposals, and presentations.
• Manages the design of service programs ensuring client need fulfillment.
• Develops and implements an annual sales and service plan including identification of potential client prospects, their needs, and the methodology of presenting company's ability to fulfill those needs.
• Meets sales goals of $2-3 million.