Sedgwick

Claims Specialist

• Analyze complex or technically difficult general liability claims to determine benefits due
• Work with high exposure claims involving litigation and rehabilitation
• Ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements
• Identify subrogation of claims and negotiate settlements
• Manage claims through well-developed action plans to an appropriate and timely resolution
• Assess liability and resolve claims within evaluation
• Negotiate settlement of claims within designated authority
• Calculate and assign timely and appropriate reserves to claims
• Manage reserve adequacy throughout the life of the claim
• Calculate and pay benefits due and approve claim payments and adjustments
• Prepare necessary state filings within statutory limits
• Manage the litigation process to ensure timely and cost-effective claims resolution
• Coordinate vendor referrals for additional investigation and/or litigation management
• Use appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients
• Manage claim recoveries including subrogation and Social Security and Medicare offsets
• Communicate claim activity and processing with the claimant and the client

Claims Examiner, Liability

• Analyzes and processes complex claims, works with high exposure claims involving litigation, and ensures ongoing claims within service expectations, industry best practices and specific client service requirements.
• Identifies and pursues potential third-party subrogation recoveries associated with highest exposure/complexity claims, all lines of business across all jurisdictions.
• Reviews high exposure, complex multi-jurisdictional claims to establish potential for third party subrogation recovery by investigating and gathering information based on feasibility of recovery analysis and employment of strategies to manage the claim through timely resolution.
• Provides subrogation guidance and direction to both internal and external stakeholders to maximize recovery efforts in alignment with client, financial and jurisdictional strategy, and guidelines.
• Develops and pursues third party subrogation, refers assignments to subrogation counsel as dictated by statute or timeline, and discusses any compromised or negotiation of the claimed subrogation interest.
• Gathers information necessary to support viable subrogation claims; documents claim notes with appropriate information.
• Maintains a diary on active claims with subrogation potential and claims that meet excess reporting criteria; ensures claim files are properly documented and claims coding is correct.

Claims Representative, Recovery

• Independently handle a capped caseload of workers' compensation claims, from inception to resolution, ensuring adherence to company procedures, industry best practices, and regulatory requirements.
• Ensure compliance with multiple state 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.
• Reporting claims to the excess carrier and responding 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 Representative – Multiple Jurisdictions & Licensing Required

Client Services Representative

• To determine account management strategies related to client service plans
• To be responsible for retention of existing clients, customer satisfaction, revenue growth, client surveys, and new business
• To provide program management for jumbo clients requiring dedicated staff, multiple offices and complex service models
• To oversee the work of other local Client Services staff
• Provides stewardship reporting to clients; identifying and educating clients on issues and trends impacting programs
• Conducts pre-renewal visits reviewing client loss experience and general company performance
• Reviews and identifies areas of potential dissatisfaction prior to renewal meetings
• Performs client renewal, contract revision, and Client Service Instruction preparation for complex programs
• Negotiates changes or improvements to service plan
• Facilitates the reduction of process barriers, technology constraints, or resource constraints by directing and influencing the activities of other internal departments such as information technology, operations and business development
• Coordinates client invoicing, audits and accounts receivable follow up for assigned clients
• Resolves all major customer service issues
• Identifies and solicits cross-selling opportunities
• Participates in local insurance community through advanced education and affiliation memberships
• Supervises and directs personnel assigned to programs requiring multiple Account Representatives
• Ensures compliance with all applicable Quality initiatives

Director, Client Services

• 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.
• Refers cases as appropriate to supervisor and management.

Workers Compensation Claims Examiner

• 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 I

Claims Examiner I, Workers Compensation, NE Jurisdiction Experience Required

Claims Examiner – Workers Compensation I

Consultant

• To address and handle high end cases with serious injuries, complex coverage scenarios and legal inquiries or disputes; to develop a strategy to bring a case to satisfactory resolution.
• Reviews/acts on reports/forms; responds to inquiries; seeks legal opinion and early resolution; and communicates resolution to appropriate parties.
• Handles high end cases with serious injuries and/or complex coverage scenarios.
• Responds to decisions, agreement, and/or court order; creates action plan; determines need for examination; gains client authorization.
• Identifies cases for settlements/redemptions.
• Gathers/documents additional information and coordinates with client designees.
• Requests legal/private investigation; assigns to and coordinates with local counsel; monitors local counsel performance.
• Responds to plaintiff's counsel, union, employee, or client requests.
• Identifies issues and formulates defense strategy.
• Establishes/adjusts accrued liability and approves administrative expenses.
• Identifies subrogation opportunities and manages process.
• Attends and participates in mediations, trials, arbitrations or hearings as needed.
• Works with partners to affect early return-to-work.
• Caseload: 90-100 litigated files

Litigation Consultant – General Liability, Licensing Required

Systems Engineer

• Partner with Property operations stakeholders, adjusters, and business leaders to gather and document detailed business requirements related to property loss workflows
• Translate requirements into well-defined user stories with clear acceptance criteria aligned to VistaClaim standards
• Support development and enhancement of VistaClaim capabilities for property claims, including intake, assignment, vendor coordination, inspection workflows, and settlement processes
• Maintain and prioritize the product backlog in alignment with Product Management and business objectives
• Actively participate in sprint planning, backlog refinement, stand-ups, and retrospectives within an Agile delivery model
• Serve as a liaison between business operations and development teams to ensure clarity of requirements and alignment on expected outcomes
• Execute functional, integration, and regression testing to validate system changes meet business and client requirements
• Identify, document, and track defects through resolution, supporting retesting and release validation
• Analyze production issues, perform root cause analysis, and partner with technical teams to implement solutions
• Support continuous improvement of VistaClaim processes, documentation standards, and delivery practices
• Contribute to overall platform consistency as VistaClaim expands beyond auto physical damage into property claims solutions

Systems Analyst – VistaClaim Property

• Analyze New York Workers Compensation Lost-Time claims on behalf of our valued clients to determine benefits due.
• Ensure ongoing adjudication of claims within service expectations and industry best practices.
• Investigate and gather information to determine exposure on the claim.
• Negotiate settlement of claims within designated authority.
• Communicate claim activity and processing with the claimant and the client.
• Report claims to the excess carrier and respond to requests of directions in a professional and timely manner.

Workers Compensation Claims Adjuster – NY Jurisdictional Knowledge, NY Licensing Required

Bilingual

• Provide world class customer service and service delivery to our clients and patients through processing referrals in the delivery of medical goods and services.
• Reaches out to patients in relation to new or already processing referrals confirming patient demographic information, providing updates on the referral, and/or confirming delivery of said goods or service.
• Communicates with vendor partners, claims adjusters and nurse case managers providing updates on new referrals as well as referrals already in process.
• Procures vendor partners for each referral as it relates to the goods or services requested.
• Responsible for making or taking phone calls on existing referrals, new referrals, or other team members referrals.
• Provides quotes back to clients for approval or follow up on quotes already sent to obtain written approval for requested referrals ensuring that each referral is deemed medically necessary and approved by the claim’s adjuster.
• Confirms all required and relevant billing information exists in each referral as it relates to the workflow and billing processes in place and moves those referrals to be billed each day.
• Processes referrals per state regulations and workers compensation guidelines.

Patient Care Coordinator – Bilingual Preferred

• To determine account management strategies related to client service plans.
• Responsible for retention of existing clients, customer satisfaction, revenue growth, client surveys, and new business.
• Provide program management for jumbo clients requiring dedicated staff, multiple offices and complex service models.
• Oversee the work of other local Client Services staff.
• Conducts pre-renewal visits reviewing client loss experience and general company performance.

Director Client Services

• Analyze reported lower-level workers compensation claims to determine benefits due
• Adjust medical-only claims and minor lost-time workers compensation claims under close supervision
• Support other claims representatives, examiners and leads with larger or more complex claims as necessary
• Process workers compensation 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
• Maintain professional client relationships

Claims Examiner, Liability

Claims Representative, Recovery

Workers Compensation Claims Representative – Multiple Jurisdictions & Licensing Required

Director, Client Services

Workers Compensation Claims Examiner

Claims Examiner, Workers Compensation I

Claims Examiner I, Workers Compensation, NE Jurisdiction Experience Required

Claims Examiner – Workers Compensation I

Claims Examiner – Workers Compensation I

Litigation Consultant – General Liability, Licensing Required

Systems Analyst – VistaClaim Property

Workers Compensation Claims Adjuster – NY Jurisdictional Knowledge, NY Licensing Required

Patient Care Coordinator – Bilingual Preferred

Director Client Services

Workers Compensation Claims Associate – Medical Only Experience Required