Claims Adjuster - Workers Compensation at Sedgwick Ontario, CA

Sedgwick; Ontario (CA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) with employer match

Paid time off

Disability insurance

Life insurance

Employee assistance program

Flexible spending account

Health savings account

Job summary

Sedgwick is seeking a Claims Adjuster for Workers Compensation in Ontario, CA. This role analyzes mid- to high-level workers comp claims, determines benefits, and guides adjudication within company standards and best practices.

Responsibilities include managing claims with respect to compensability, reserves, and subrogation, coordinating return-to-work, and communicating with claimants and clients. Bachelor's degree preferred, 4 years’ claims experience, and strong negotiation skills are

Qualifications

• Bachelor’s degree from an accredited college or university preferred.
• Four (4) years of claims management experience or equivalent required.
• Knowledge of regulations, offsets, disability duration, and medical management.
• Strong written and oral communication skills.
• Proficiency with Microsoft Office and PC literacy.

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 including state/physician filings and decisions on treatments.
• Maintains professional client relationships.

Skills

Regulations knowledge

Communication skills

MS Office

Analytical skills

Organizational skills

Interpersonal skills

Negotiation skills

Teamwork

Service orientation

Education

Bachelor’s degree

Tools

Microsoft Office

Job description

Claims Adjuster - Workers Compensation

Ontario, CA. Job Title: Claims Adjuster – Workers Compensation.

PRIMARY PURPOSE

To analyze mid- and higher‑level workers compensation claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements.

ESSENTIAL FUNCTIONS AND 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.

ADDITIONAL FUNCTIONS AND RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organization’s quality program(s).
• Travels as required.

QUALIFICATIONS

Education & Licensing

Bachelor’s degree from an accredited college or university preferred.

Experience

Four (4) years of claims management experience or equivalent combination of education and experience required.

Skills & Knowledge

• 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.

Work Environment

When applicable and appropriate, consideration will be given to reasonable accommodations.

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.

Benefits

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is \$70,000 - \$90,000 per year. A comprehensive benefits package is offered including but not limited to medical, dental, vision, 401(k) and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

Equal Opportunity Employer Statement

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

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.