Sedgwick

Bilingual

• To analyze mid- and higher-level general auto claims to determine scope of damages
• To ensure ongoing adjudication of claims within company standards and industry best practices
• To identify subrogation of claims and negotiate settlements
• Manages mid-level and higher-level auto commercial and personal lines claims by gathering information to determine 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
• Ensures claim files are properly documented and claims coding is correct

Auto Desk Adjuster, Bilingual – Spanish

Therapist

• Counsels providers (physical therapists, occupational therapists, and physicians) as it pertains to the appropriate use, cadence, and duration of physical therapy services.
• Monitors the impact of physical therapy services provided to injured workers.
• Provides medical necessity reviews to evaluate and implement services to meet client health needs.
• Promotes quality cost-effective physical therapy outcomes.
• Reviews medical records and physical therapy (PT) treatment plans to ensure they meet the appropriate guidelines while also ensuring best possible recovery.
• Determines the medical necessity and appropriateness of physical therapy services according to policy and develops action plans for providers as it pertains to current and future treatment.
• Provides clinical opinions regarding physical therapy needs and communicates with providers about therapy protocols and guidelines.
• Liaises and negotiates with physical therapists, occupational therapists, physicians, and other stakeholders to optimize patient care and promote effective use of resources.
• Consults with Sedgwick clinical team on difficult claims and provides recommendations tied to improving care and overall claim outcomes.
• Supports clinical product innovation for Sedgwick in conjunction with both internal and external stakeholders.
• Documents all communications, decisions, and steps taken in the claim process in a timely and accurate manner.
• Participates in client meetings and phone calls to explain program results.
• Supports complex claim roundtable discussions.
• Participates in quality assurance activities, including audits and peer reviews, to ensure adherence to clinical guidelines and standards, as well as identifying opportunities for improvement.
• Stays updated with relevant industry regulations, guidelines, and best practices related to utilization review and maintains compliance with applicable laws and regulations.

Physical Therapy Utilization Review Advisor

Claims Specialist

• To analyze and process low to mid-level auto and transportation claims
• Processes auto property damage and lower level injury claims; assesses damage, makes payments, and ensures claim files are properly documented and correctly coded based on the policy
• Develops and maintains action plans to ensure state required contract deadlines are met and to move the file towards prompt and appropriate resolution
• Identifies and pursues subrogation opportunities; secures and disposes of salvage
• Communicates claim action/processing with insured, client, and agent or broker when appropriate
• Maintains professional client relations
• Performs coverage, liability, and damage analysis on all claims assignments
• Performs other duties as assigned
• Supports the organization's quality program(s)

Claims Representative – Auto

• Analyzes and processes complex or technically difficult medical malpractice 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
• Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions
• Negotiates claim settlement up to designated authority level
• Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout claim life
• Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement
• Coordinates legal defense by assigning attorney, coordinating support for investigation, and reviewing attorney invoices; monitors counsel for compliance with client guidelines
• Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall claim cost for our clients
• Identifies and investigates for possible fraud, subrogation, contribution, recovery, and case management opportunities to reduce total claim cost
• Represents Company in depositions, mediations, and trial monitoring as needed
• Communicates claim activity and processing with 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
• Delegates work and mentors assigned staff

Senior Claims Specialist, Professional Liability

Recruitment

• Manage staffing activities associated within a designated region
• Partner with Operational management to formulate and execute timely, cost-effective staffing initiatives supporting regional and corporate business objectives
• Identify and cultivate sources for hiring experienced and entry level personnel through networking and colleague referrals
• Develop and utilize Internet Mining technology and capabilities
• Maintain a competitor candidate information database
• Initiate a candidate relationship “pipeline management” strategy
• Utilize current and future staffing technology
• Manage Recruiting budget for the region through cost-effective advertisement and third-party recruiters
• Develop preferred supplier list of third-party recruiters
• Negotiate discounted contract rates for staffing needs with the National Director of staffing
• Screen, interview, and test job applicants as required
• Maintain applicant database utilizing electronic recruiting software
• Provide key staffing metrics for regional hiring
• Track regional colleague retention
• Consult with regional management regarding issues affecting turnover
• Train and mentor hiring managers and Colleague Resource Generalists in the use of electronic recruiting software
• Build skill level of regional users by providing training on system updates and new user training
• Promote and assist Colleague Resources Managers in training hiring managers in the use of Behavioral Interviewing Techniques and other candidate assessment tools and processes
• Support and provide training for the Colleague Resources Generalists in staffing techniques

Talent Acquisition Specialist

Operations

• To oversee technical and operational functions including compliance with company standards and industry best practices
• To ensure consistent delivery of quality services
• To oversee staffing and training needs
• To oversee budget preparation and profit and loss management
• Has direct responsibility for less than 25 colleagues
• Oversees internal quality review process and reports monthly
• Assures compliance with client internal controls, audit requirements and service agreement requirements
• Establishes business plan with goals and objectives for assigned clients
• Ensures claims management policies and procedures are followed to assure meeting service standards, state statutes/regulations, disability plan document, industry best practices and client service requirements
• Establishes and maintains client contacts
• Performs other duties as assigned
• Supports the organization's quality program(s)
• Travels as required

Operations Manager

Customer Support

• Coordinate and manage lease extensions and ongoing housing support needs for displaced policyholders in a fast-paced, service-driven environment.
• Ensure continuity of housing by proactively managing extensions, resolving in-stay service issues, and maintaining strong communication between insureds, adjusters, and landlords.
• Serve as a key point of contact for adjusters and landlords during the insured's relocation, ensuring consistent communication, clear expectations, and empathetic support during extensions and ongoing service needs.
• Manage the full lease extension process including requesting and securing approvals from adjusters, coordinating updated lease terms with landlords and vendors and communicating timelines and expectations to policyholders.
• Proactively monitor upcoming lease expirations to prevent service interruptions and ensure seamless housing continuity.
• Coordinate and resolve in-stay service requests including furniture exchanges, add-ons, and maintenance-related concerns.
• Collaborate with landlords, property managers, and vendors to execute timely service solutions and extension agreements.
• Investigate and resolve issues related to property conditions, damages, and vendor performance.
• Maintain accurate financial and operational records, including: updating client ledgers for billing accuracy, tracking extension costs within ALE guidelines, manage move-out coordination when applicable, including vendor pickups, lease terminations, and security deposit reconciliation.
• Document all communication, updates, and actions in internal systems with a high level of accuracy and timeliness.
• Identify risks, delays, or service failures early and escalate appropriately with ownership and urgency.
• Maintain a high-touch service model for all clients, including VIP or complex claims requiring elevated coordination.
• Handle multiple claims simultaneously while meeting service level expectations and deadlines.

Housing Support Specialist

• Analyzes and processes complex or technically difficult medical malpractice claims
• Manages claims through well-developed action plans to an appropriate and timely resolution
• Conducts or assigns full investigation and provides report of investigation pertaining to new events, claims and legal actions
• Negotiates claim settlement up to designated authority level
• Monitors reserve adequacy throughout claim life
• Recommends settlement strategies; brings structured settlement proposals as necessary to maximize settlement
• Coordinates legal defense by assigning attorney, coordinating support for investigation, recognizing opportunities to reduce total claim cost
• Communicates claim activity and processing with the client
• Ensures claim files are properly documented and claims coding is correct
• Refers cases as appropriate to supervisor and management
• Delegates work and mentors assigned staff

Senior Claims Specialist – Professional Liability

Medical Director

• To evaluate medical reports escalated due to deficient information utilizing evidence based criteria;
• To provide leadership within the dedicated team of clinician and claim professionals.
• Participate in client stewardship discussions, claim roundtables, and complex medical escalations.
• Stay current on emerging medical trends, treatment standards, clinical literature, and evidence-based guidelines;
• Support workers’ compensation, disability, FMLA, fitness-for-duty, return-to-work, liability, and safety-sensitive workforce issues.
• Obtain and maintain Medical Director licensure in a few select states, as needed.
• Apply applicable clinical guidelines and medical literature to support defensible recommendations, claim discussions, and treatment-plan clarification.
• Engage treating providers when needed and support appeals, independent medical review considerations, peer review alignment, and clinical quality review.
• Documenting recommendations within templates in Juris and SharePoint using the appropriate format referencing evidence-based criteria within the required time frame.
• Developing and delivering training materials and presentations to meet training needs.
• Interfacing and providing guidance and leadership to the Client dedicated leadership team as well as team leads.

SVP Medical Director

Analyst

• To coordinate new and/or renewal business pricing process and identify program trends impacting pricing
• Provide support to operational directors, program and office managers in the development of program pricing and design
• Provide support for program implementations and department initiatives
• Review contracts and provide billing instructions to the billing group
• Assist in the design and pricing of client renewals; support operations in renewal development
• Work closely with other departments and communicate often with program managers, operations manager, managing departments, and legal department
• Generate ad hoc reporting and analysis as requested by management
• Compile and analyze financial data and make recommendations for improved data capturing and analytics
• Assist in the evaluation, development, and enhancement of various pricing models
• Provide superior customer service and support to business/management strategies

Program Design Analyst

• 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

QA Engineer

• Provide service transaction monitoring to service center assistants (SCAs) and service center representatives (SCRs)
• Determine customer call quality and effectiveness of customer contact responses and interactions
• Manage daily workflow
• Complete assignments by their due date unless business needs dictate otherwise
• Complete the designated weekly/monthly audits for assigned business products
• Report individual audit results to the appropriate managers for their use when completing evaluations
• Be a technical expert on the functions and products you audit
• Mentor new members of the Quality team
• Develop Representatives in the functions you audit
• Provide feedback confidentially and in a professional manner to representatives about their performance
• Give/receive feedback efficiently and effectively
• Identify opportunities for process improvements
• Provide coaching when opportunities need to be addressed
• Endeavor to learn new skills that support the business organization

Quality Assurance Associate

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
• 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
• Performs other duties as assigned
• Supports the organization's quality program(s)

Manager, Client Services

• Manages mid-level water damage 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.
• Assesses liability and resolves claims within evaluation.
• 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.
• Performs other duties as assigned.
• Supports the organization's quality program(s).

Claims Examiner - Workers Compensation

Human Resources

• To serve as the point of contact and provide support, guidance, and direction to business leaders and CR business partners
• Reviews, documents, and delivers feedback and/or progressive discipline actions up to and including termination
• Provides advice, consultation, guidance, and coaching to business leaders
• Ensures accurate tracking, intake and investigation notes, documentation, and resolution of employee relations cases.