Sedgwick

Claims Specialist

• Analyze mid- and higher-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
• Manage workers compensation claims determining compensability and benefits due on long term indemnity claims
• Monitor reserve accuracy and file necessary documentation with state agency
• Develop and manage workers compensation claims' action plans to resolution
• Approve and process assigned claims and determine benefits due
• Manage subrogation of claims and negotiate settlements
• Communicate claim action with claimant and client
• Ensure claim files are properly documented and claims coding is correct
• Maintain professional client relationships

Claims Adjuster – WC

Director

• Responsible for overall operations management for all assigned locations/offices.
• Establishes policy and procedures to assure compliance to best practices, claims management services standards, state regulations, and client service requirements.
• Establishes business plan with goals and objectives for the partnership and locations/offices.
• Monitors management reports relating to the partner/office performance.
• Assists with the coordination of sales and client service efforts.
• Travels as required.
• Administers company personnel policies in all areas and follows company staffing standards and training recommendations.
• Interviews, hires and establishes colleague performance development plans; conducts colleague performance discussions.
• Provides support, guidance, leadership and motivation to promote maximum performance.

Director, Claims

• 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

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Claims Representative, Auto

Claims Examiner – Workers Compensation

Liability Claims Representative – CA, OH, IN, KY Jurisdictional Knowledge – Licensing Required

• Analyze complex or technically difficult occupational accident 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.
• Manages claims through well-developed action plans to an appropriate and timely resolution.

Claims Examiner, Auto – Occupational Accident

• 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
• Communicate claim action/processing with claimant, client and appropriate medical contact
• Ensure claim files are properly documented and claims coding is correct
• Process routine payments and prescriptions and status reports for lifetime medical claims and/or defined period medical claims
• Maintain professional client relationships

Liability Claims Associate

• 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 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.
• 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 – NY Jurisdictions, NY Licensing Required

• To analyze moderately complex Auto Bodily Injury and Property Damage 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.

Claims Adjuster – Bodily Injury

• Analyze reported lower-level general liability 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 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 for medical claims

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.

Claims Adjuster - Liability, GL and Litigation

Manager

• Partnering with the injured worker, employer, and medical providers to create a case management strategy
• Facilitating medical recovery and a successful return to work through advocacy, communication and coordination of medical services
• Working in a collaborative environment to assist in the management of complex medical conditions and treatment planning
• Communicating and building relationships with the claims’ examiner, client, injured worker, attorney and supervisor
• Identifying issues related to delayed recovery and problem solving with a creative thinking approach

Telephonic Case Manager

Operations

• To supervise Operations Support Services (OSS) staff and processes
• To monitor colleagues' workloads
• To provide training and monitor individual transactions
• To provide technical direction on work processes
• Defines and establishes quality assurance procedures, standards, metrics reporting and auditing
• Trains OSS team on tasks and responsibilities
• Reviews quality data, conducts audits, tracks quality metrics, and reports on findings
• Tracks non-compliance issues and monitors through resolution
• Manages staffing schedules to assure appropriate department coverage
• Performs other duties as assigned
• Supports the organization's quality program(s)
• Travels as required

Operations Support Services – Team Lead

• 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.