Claims Examiner - Workers Compensation - Brea, CA; Hybrid

Position: Claims Examiner - Workers Compensation - Brea, CA (Hybrid)
** Claims Examiner - Workers Compensation - Brea, CA (Hybrid)
**** Claims Examiner - Workers Compensation - Brea, CA (Hybrid)
** Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs.

It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive. A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here.

Join us and contribute to Sedgwick being a great place to work.

Great Place to Work  Most Loved Workplace   Forbes Best-in-State Employer Claims Examiner - Workers Compensation - Brea, CA (Hybrid)
** 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
*…