Claims Examiner - Workers Compensation (REMOTE - Needs SE state Exp FL, GA, NC, SC, TN, AL)

Sedgwick; Atlanta (GA); Remote; USD 50,000 - 80,000; Full time

Job summary

Join a forward-thinking company as a Claims Examiner, where you will analyze complex workers' compensation claims and ensure timely resolutions. This role offers a unique opportunity to apply your expertise in a collaborative environment, focusing on negotiation, communication, and problem-solving skills. With a commitment to work-life balance and a culture that values diversity and inclusion, you will thrive in an atmosphere that encourages professional growth. If you're ready to make a meaningful impact in the lives of others while advancing your career, this position is perfect for you.

Qualifications

• 5+ years of claims management experience required.
• Bachelor's degree preferred; professional certification is a plus.

Responsibilities

• Analyze and process complex workers' compensation claims.
• Negotiate settlements and manage claims effectively.
• Ensure timely and accurate claim payments and adjustments.

Skills

Insurance Principles

Negotiation Skills

Analytical Skills

Communication Skills

Organizational Skills

Interpersonal Skills

Teamwork

Cost Containment Principles

Education

Bachelor's Degree

Tools

Microsoft Office

Job description

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 - Workers Compensation (REMOTE - Needs SE state Exp FL, GA, NC, SC, TN, AL)

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

1. Analyze and process complex or technically difficult workers' compensation claims by investigating and gathering information to determine the exposure on the claim; manage claims through well-developed action plans to an appropriate and timely resolution.
2. Negotiate settlement of claims within designated authority.
3. Calculate and assign timely and appropriate reserves to claims; manage reserve adequacy throughout the life of the claim.
4. Calculate and pay benefits due; approve and make timely claim payments and adjustments; and settle claims within designated authority level.
5. Prepare necessary state filings within statutory limits.
6. Manage the litigation process; ensure timely and cost-effective claims resolution.
7. Coordinate vendor referrals for additional investigation and/or litigation management.
8. Use appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
9. Manage claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries, and Social Security and Medicare offsets.
10. Report claims to the excess carrier; respond to requests of directions in a professional and timely manner.
11. Communicate claim activity and processing with the claimant and the client; maintain professional client relationships.
12. Ensure claim files are properly documented and claims coding is correct.
13. Refer cases as appropriate to supervisor and management.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

1. Perform other duties as assigned.
2. Support the organization's quality program(s).
3. Travel 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 an 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.