Claims Examiner- Worker's Compensation

Sedgwick Claims Management Services Ltd; Southfield (MI); Sur place; USD 65 000 - 90 000; Plein temps

Résumé du poste

Sedgwick is seeking a Claims Examiner- Workers' Compensation to analyze complex claims, determine benefits, and manage high-exposure cases through adjudication and rehabilitation.

The role requires a Bachelor's degree and at least five years in claims management, with strong negotiation, analytical, and communication skills. You will work with clients, vendors, and internal teams to ensure timely resolutions and cost-effective outcomes.

Qualifications

• Bachelor's degree preferred.
• Five years of claims management experience or equivalent required.
• Professional certification applicable to line of business preferred.

Responsabilités

• Analyzes and processes complex workers' compensation claims to determine exposure and benefits.
• Negotiates settlements within designated authority.
• Calculates reserves and ensures adequacy throughout the life of the claim.
• Prepares state filings within statutory limits and manages litigation processes.
• Coordinates vendor referrals for investigation or litigation management.
• Uses cost containment techniques including vendor partnerships to reduce claim costs.
• Manages claim recoveries including subrogation and offsets.

Connaissances

Communication

Analytical skills

Organizational skills

Interpersonal skills

Negotiation

Teamwork

Service orientation

Formation

Bachelor's degree

Description du poste

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance 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 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 and a Drug-Free Workplace

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway

Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles

Sedgwick is the world’s leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company’s expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see sedgwick.com