Claims Examiner- Worker's Compensation

Sedgwick; Southfield (MI); On-site; USD 65,000 - 90,000; Full time

Job summary

Sedgwick is seeking a Claims Examiner (Worker's Compensation) in Michigan to analyze complex WC claims, determine benefits, and support litigation and rehabilitation efforts. The role requires handling high-exposure cases, subrogation, and settlements within authority limits.

Ideal candidates will have a bachelor's degree with at least five years of claims management experience, strong analytical and negotiation skills, and proficiency in Microsoft Office. Travel may be required.

Qualifications

• 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.
• Subject matter expert of appropriate insurance principles and laws for line-of-business handled.
• Excellent oral and written communication, including presentation skills.

Responsibilities

• Analyzes and processes complex workers' compensation claims by investigating and gathering information to determine exposure.
• Negotiates settlements within designated authority.
• Calculates and assigns 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.
• Prepares state filings within statutory limits.
• Manages the litigation process and costs.
• Coordinates vendor referrals for investigation or litigation management.
• Drives subrogation and cost containment efforts for clients.
• Communicates claim activity with claimants and clients; maintains professional relationships.

Skills

Claims management

Analytical skills

Negotiation

Communication

Teamwork

Microsoft Office

Education

Bachelor's degree

Professional certification

Tools

Microsoft Office

Job description

Claims Examiner- Worker's Compensation

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

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

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

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

Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience.