Claims Examiner Workers Compensation
Posted on: August 14, 2019
Claims Examiner Workers Compensation
IF YOU CARE, THERE'S A PLACE FOR YOU HERE
For a career path that is both challenging and rewarding, join
Sedgwick's talented team of 21,000 colleagues around the globe.
Sedgwick is a leading provider of technology-enabled risk, benefits
and integrated business solutions. Taking care of people is at the
heart of everything we do. Millions of people and organizations
count on Sedgwick each year to take care of their needs when they
face a major life event or something unexpected happens. Whether
they have a workplace injury, suffer property or financial loss or
damage from a natural or manmade disaster, are involved in an auto
or other type of accident, or need time away from work for the
birth of a child or another medical situation, we are here to
provide compassionate care and expert guidance. Our clients depend
on our talented colleagues to take care of their most valuable
assets -- their employees, their customers and their property. At
Sedgwick, caring counts--. Join our team of creative and caring
people of all backgrounds, and help us make a difference in the
lives of others.
For nearly 50 years, Sedgwick has been helping employers answer
virtually every question there is about workers' compensation. We
have experience in nearly every type of industry, in every region,
providing the broadest range of programs and services.
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
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
- Negotiates settlement of claims within designated
- Calculates and assigns timely and appropriate reserves to
claims; manages reserve adequacy throughout the life of the
- Calculates and pays benefits due; approves and makes timely
claim payments and adjustments; and settles clams within designated
- Prepares necessary state fillings within statutory
- 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
- 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
- Ensures claim files are properly documented and claims coding
- 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.
Education & Licensing
Bachelor's degree from an accredited college or university
preferred. Professional certification as applicable to line of
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
- Excellent oral and written communication, including
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Excellent interpersonal skills
- Excellent negotiation skills
- Ability to work in a team environment
- Ability to meet or exceed Service Expectations
When applicable and appropriate, consideration will be given to
Mental: Clear and conceptual thinking ability; excellent judgment,
troubleshooting, problem solving, analysis, and discretion; ability
to handle work-related stress; ability to handle multiple
priorities simultaneously; and ability to meet deadlines
Physical: Computer keyboarding, travel as required
Auditory/Visual: Hearing, vision and talking
NOTE: Credit security clearance, confirmed via a background credit
check, is required for this position.
The statements contained in this document are intended to describe
the general nature and level of work being performed by a colleague
assigned to this description. They are not intended to constitute a
comprehensive list of functions, duties, or local variances.
Management retains the discretion to add or to change the duties of
the position at any time.
Sedgwick is an Equal Opportunity Employer
**Must currently meet the requirements for designation under
AB1262, or have California Self-Insurers Certificate (SIP) or
AB1262 California Experienced Examiner Designation. WCCA, WCCP
Keywords: Sedgwick, Riverside , Claims Examiner Workers Compensation, Other , Riverside, California
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