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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.
Claims Examiner – Workers Comp
Location
Ohio
Posted
15 days ago
Salary
$73K - $75K / year
Seniority
Senior
Job Description
Claims Examiner – Workers Comp
Sedgwick
• To analyze complex or technically difficult workers compensation claims to determine benefits due; • to work with high exposure claims involving litigation and rehabilitation; • and to ensure ongoing adjudication of claims within company standards and industry best practices or client specific requirements. • Analyzes and processes complex or technically difficult claims by investigating and gathering information to assist employer in determining their position on the claim; • manages claims through well-developed action plans to an appropriate and timely resolution. • Works to move claim towards appropriate claim closure which may include referral for settlement evaluation. • Monitors reserve adequacy throughout the life of the claim if applicable. • Monitors and reviews benefits due and payment calculations ensuring accuracy. • Prepares necessary state filings within statutory limits. • Follows best practice standards in contested claims including outside legal representation. • 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. • Participates in claim recoveries including, but not limited to: subrogation, Second Injury Fund recoveries, and Social Security offsets. • Communicates claim action/processing with appropriate parties including, but not limited to: claimant, client, state agency, managed care organization and appropriate medical contact. • Ensures claims files are properly documented and claims coding is correct. • Maintains professional client relationships. • Coordinates actuarial/settlement issues impacting employers with rate and settlement departments. • Assesses policy level status of clients; works in coordination with clients' service expectations and assigned service personnel.
Job Requirements
- Bachelor's degree from an accredited college or university preferred.
- Licenses as required.
- Professional certification as applicable to line-of-business preferred.
- Four (4) years claims management experience or equivalent combination of education and experience required.
- In-depth line-of-business knowledge of appropriate insurance principles and laws, recoveries offsets and deductions, and cost containment principles
- Excellent oral and written communication skills, including presentation skills
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Good interpersonal skills
- Ability to work in a team environment
- Ability to meet or exceed Performance Competencies.
Benefits
- Three Medical, and two dental plans to choose from.
- Tuition reimbursement eligible.
- 401K plan that matches 50% on every $ you put in up to the first 6% you save.
- 4 weeks PTO your first full year.
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