Claims Adjuster - Workers Compensation (Hourly)

Sedgwick Claims Management Services•El Dorado Hills, CA

15h•Onsite

About The Position

This position analyzes mid- and higher-level workers compensation claims to determine benefits due. The role ensures ongoing adjudication of claims within company standards and industry best practices, and identifies subrogation of claims and negotiates settlements. The Claims Examiner will manage workers compensation claims, determining compensability and benefits due on long-term indemnity claims, monitoring reserve accuracy, and filing necessary documentation with state agencies. They will develop and manage workers compensation claims' action plans to resolution, coordinate return-to-work efforts, and approve claim payments. The role involves approving and processing assigned claims, determining benefits due, and managing action plans pursuant to the claim or client contract. Additionally, the Claims Examiner will manage subrogation of claims and negotiate settlements, communicate claim actions with claimants and clients, and ensure claim files are properly documented with correct claims coding. This role may also process complex lifetime medical and/or defined period medical claims, including state and physician filings and decisions on appropriate treatments recommended by utilization review. Maintaining professional client relationships is also a key aspect of this position.

Requirements

Working knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure 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 skill
Good interpersonal skills
Excellent negotiation skills
Ability to work in a team environment
Ability to meet or exceed Service Expectations

Responsibilities

Manages workers compensation claims determining compensability and benefits due on long term indemnity claims, monitors reserve accuracy, and files necessary documentation with state agency.
Develops and manages workers compensation claims' action plans to resolution, coordinates return-to-work efforts, and approves claim payments.
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).