Senior Claims Examiner

By joining Sedgwick, you'll be part of something truly meaningful. Its 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, theres no limit to what you can achieve.

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Senior Claims Examiner

**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; and to ensure ongoing adjudication of claims within company standards and industry best practices or client specific requirements.

**ESSENTIAL FUNCTIONS and RESPONSIBILITIES**

+ 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.

**ADDITIONAL FUNCTIONS AND RESPONSIBILITIES**

+ Performs other duties as assigned.

+ Supports the organization's quality program(s).

**QUALIFICATIONS**

**Education & Licensing**

Bachelor's degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line-of-business preferred.

**Experience**

Four (4) years claims management experience or equivalent combination of education and experience required.

**Skills & Knowledge**

+ 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

**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 worlds leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The companys 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**