The Claims Examiner is responsible for the accurate and timely processing of medical, dental, vision and prescription drug claims. The incumbent is expected to provide courteous and prompt responses to customer inquiries. The incumbent is expected to communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public, and to be respectful and courteous in the conduct of this position. ESSENTIAL JOB FUNCTIONS: - Essential job functions include the following. Other functions may be assigned as business conditions change. - Verifies the accuracy and receipt of all required documentation for each claim submitted. - Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim. - Analyzes information necessary for processing. This includes, but is not limited to, general participant and provider information, managed care affiliation, diagnosis codes, dates, place, type of service, procedure codes, and charges. - Assures that the system processes the claim correctly and determines payment according to the plan as written. - Word-processes correspondence to plan participants and providers in reference to pre-determinations and in response to basic benefit questions. - Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries. - Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims. - Assigns critically ill patients to large case management. Assists the case manager with direct negotiation and the efficient use of benefits. - Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent. - Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review. - Researches, calculates and requests refunds when necessary. - Contributes to the daily workflow with regular and punctual attendance. - Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department. - Process eligible claims on groups before the end of their stoploss contract renewal period. - Assists the Legal Department with subrogation claims as necessary. - Attends various group meetings as required. - Assists with audits as needed. - Assists with plan benefit set-up and changes as needed. Minimum Education: High school graduation or GED required. Minimum Experience: Basic computer and customer service experience required. Other Qualifications: - Excellent oral and written communication skills required. - PC skills, including Windows and Word. - Ability to learn all functions of the claims processing software as is necessary for claims processing and adjudication. - Must be able to adapt to software changes as they occur. - Typing ability of 45 wpm net - Excellent listening skills. - Basic mathematical skills. - High level of interpersonal skills to work effectively with others. - Ability to organize and recall large amounts of detailed information. - Ability to read, analyze and interpret benefit summary plan descriptions, insurance documents, plan benefits, and regulations and make appropriate applications to specific situations. - Ability to meet productivity standards with 99% financial accuracy and 95% procedural accuracy. - Thorough knowledge of claims processing procedures and requirements. - Ability to project a professional image and positive attitude in any work environment. - Ability to comply with privacy and confidentiality standards. - Ability to be flexible, work under pressure and meet deadlines. - Ability to analyze and solve problems with professionalism and patience, and to exercise good judgment when making decisions. - Ability to operate typical office equipment. - Working knowledge of general office procedures. About Allegiance by Cigna Healthcare Since 1981, Allegiance by Cigna Healthcare has specialized in administering medical benefits, including claims processing, customer service, utilization management, and case management. With a high‑touch approach to member and client service, Allegiance supports some of the nation’s most innovative health benefit strategies. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life. We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality. Join us in driving growth and improving lives. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws. If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response. The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

• Responsible for the accurate and timely processing of medical, dental, vision and prescription drug claims. • Provide courteous and prompt responses to customer inquiries. • Communicate professionally with peers, supervisors, subordinates, vendors, customers, and the public. • Verifies the accuracy and receipt of all required documentation for each claim submitted. • Collaborates with providers, plan participants, other claims payers, or any other party necessary to obtain information necessary to accurately process a claim. • Analyzes information necessary for processing. • Assures that the system processes the claim correctly and determines payment according to the plan as written. • Answers telephone calls from plan participants, group contacts, and customer service representatives pertaining to benefits and claims inquiries. • Resolves problematic claims with the assistance of the Team Leader, Claims Manager and/or the Director of Claims. • Assigns critically ill patients to large case management. • Assists other examiners as needed due to workload requirements, including assigned back-up when examiners are absent. • Aids the Team Leader and/or the Claims Manager in the resolution of claim appeals and disputes by providing documentation for review. • Researches, calculates and requests refunds when necessary. • Contributes to the daily workflow with regular and punctual attendance. • Thoroughly researches and completes renewal reports in a timely manner in consultation with the Marketing Department. • Process eligible claims on groups before the end of their stoploss contract renewal period. • Assists the Legal Department with subrogation claims as necessary. • Attends various group meetings as required. • Assists with audits as needed. • Assists with plan benefit set-up and changes as needed.

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, Auto | Bodily Injury | Remote PRIMARY PURPOSE: To analyze and process complex auto and commercial transportation claims by reviewing coverage, completing investigations, determining liability and evaluating the scope of damages. ESSENTIAL FUNCTIONS and RESPONSIBILITIES - Processes complex auto commercial and personal line claims, including bodily injury and ensures claim files are properly documented and coded correctly. - Responsible for litigation process on litigated claims. - Coordinates vendor management, including the use of independent adjusters to assist the investigation of claims. - Reports large claims to excess carrier(s). - Develops and maintains action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution. - Identifies and pursues subrogation and risk transfer opportunities; secures and disposes of salvage. - Communicates claim action/processing with insured, client, and agent or broker when appropriate. 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. Professional certification as applicable to line of business preferred. Secure and maintain the State adjusting licenses as required for the position. Experience Five (5) years of claims management experience or equivalent combination of education and experience required to include in-depth knowledge of personal and commercial line auto policies, coverage’s, principles, and laws. Skills & Knowledge - In-depth knowledge of personal and commercial line auto policies, coverage’s, principles, and laws - Knowledge of medical terminology for claim evaluation and Medicare compliance - Knowledge of appropriate application for deductibles, sub-limits, SIR’s, carrier and large deductible programs. - Strong oral and written communication, including presentation skills - PC literate, including Microsoft Office products - Strong organizational skills - Strong interpersonal skills - Good 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 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 $80,000 to $85,000. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits. Always accepting applications. 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. 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.

• Analyze and process complex auto and commercial trucking transportation claims by reviewing coverage, completing investigations, determining liability and evaluating the scope of damages. • Process complex auto commercial trucking and personal line claims, including bodily injury and ensure claim files are properly documented and coded correctly. • Responsible for litigation process on litigated claims. • Coordinate vendor management, including the use of independent adjusters to assist the investigation of claims. • Report large claims to excess carrier(s). • Develop and maintain action plans to ensure state required contact deadlines are met and to move the file towards prompt and appropriate resolution. • Identify and pursue subrogation and risk transfer opportunities; secure and dispose of salvage. • Communicate claim action/processing with insured, client, and agent or broker when appropriate.