Claims Examiner - Workers Compensation - Hybrid Schedule

Sedgwick • Pasadena, CA

416d • $75,000 - $100,000

About The Position

The Claims Examiner for Workers Compensation at Sedgwick is responsible for analyzing complex workers' compensation claims to determine benefits due, managing high exposure claims involving litigation and rehabilitation, and ensuring claims are adjudicated within service expectations and industry best practices. This role requires effective negotiation skills and the ability to manage claims through well-developed action plans, while also maintaining professional relationships with clients and claimants.

Requirements

• Bachelor's degree from an accredited college or university preferred.
• Five (5) years of claims management experience or equivalent combination of education and experience required.
• Professional certification as applicable to line of business preferred.
• Subject matter expert of appropriate insurance principles and laws for line-of-business handled.
• 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.

Responsibilities

• Analyze and process complex workers' compensation claims by investigating and gathering information to determine exposure.
• Manage claims through well-developed action plans to an appropriate and timely resolution.
• 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; approve and make timely claim payments and adjustments; settle claims within designated authority level.
• Prepare necessary state filings within statutory limits.
• Manage the litigation process; 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.
• Manage claim recoveries, including subrogation and Social Security and Medicare offsets.
• Report claims to the excess carrier; respond to requests for directions in a professional and timely manner.
• Communicate claim activity and processing with the claimant and the client; maintain professional client relationships.
• Ensure claim files are properly documented and claims coding is correct.
• Refer cases as appropriate to supervisor and management.

Benefits

• Medical insurance
• Dental insurance
• Vision insurance
• 401k and matching
• Paid Time Off (PTO)
• Disability insurance
• Life insurance
• Employee assistance program
• Flexible spending account or health savings account
• Other additional voluntary benefits

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree