Claims Examiner - Workers Compensation - Remote Nationwide

Sedgwick

null

United States

Customer Service / Call Center
(No Timezone Provided)

PRIMARY PURPOSE

: To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

  • 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 clams within designated authority level.

  • Prepares necessary state fillings 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.

  • ADDITIONAL FUNCTIONS and RESPONSIBILITIES

  • Performs other duties as assigned.

  • Supports the organization's quality program(s).

  • Travels as required.

  • QUALIFICATION

    Education & Licensing
    Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.

    Experience

  • Colorado and Utah Workers Compensation Claims Handling experience required.

  • Five (5) years of claims management experience or equivalent combination of education and experience required.

  • Skills & Knowledge

  • Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business.

  • Excellent oral and written communication, including presentation skills

  • PC literate, including Microsoft Office products

  • Analytical and interpretive skills

  • Strong organizational skills

  • Good interpersonal skills

  • Excellent negotiation skills

  • Ability to work in a team environment

  • Ability to meet or exceed Service Expectations

  • Claims Examiner - Workers Compensation - Remote Nationwide

    Sedgwick

    null

    United States

    Customer Service / Call Center

    (No Timezone Provided)

    PRIMARY PURPOSE

    : To analyze complex or technically difficult workers' compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; to ensure ongoing adjudication of claims within service expectations, industry best practices and specific client service requirements; and to identify subrogation of claims and negotiate settlements.

    ESSENTIAL FUNCTIONS and RESPONSIBILITIES

  • 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 clams within designated authority level.

  • Prepares necessary state fillings 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.

  • ADDITIONAL FUNCTIONS and RESPONSIBILITIES

  • Performs other duties as assigned.

  • Supports the organization's quality program(s).

  • Travels as required.

  • QUALIFICATION

    Education & Licensing
    Bachelor's degree from an accredited college or university preferred. Professional certification as applicable to line of business preferred.

    Experience

  • Colorado and Utah Workers Compensation Claims Handling experience required.

  • Five (5) years of claims management experience or equivalent combination of education and experience required.

  • Skills & Knowledge

  • Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures as applicable to line-of-business.

  • Excellent oral and written communication, including presentation skills

  • PC literate, including Microsoft Office products

  • Analytical and interpretive skills

  • Strong organizational skills

  • Good interpersonal skills

  • Excellent negotiation skills

  • Ability to work in a team environment

  • Ability to meet or exceed Service Expectations