Workers Compensation Claims Examiner | West Hills, CA; Remote

Workers Compensation Claims Examiner | West Hills, CA (Remote 2 Days) – Sedgwick

By joining Sedgwick, you'll be part of a global leader committed to helping people when they face unexpected challenges. You will grow your career and enjoy work-life balance in a caring culture.

• Apply your knowledge and experience to adjudicate complex customers’ claims in a dynamic environment.
• Deliver innovative solutions to clients across virtually every industry.
• Be part of a rapidly growing, industry-leading company known for excellence and customer service.
• Leverage Sedgwick’s global network of experts to learn and share insights.
• Take advantage of professional development opportunities to grow your career.
• Enjoy flexibility and autonomy in work location and career path.
• Access comprehensive benefits for mental, physical, financial and professional needs.

We look for driven individuals who embody our caring counts model and core values: empathy, accountability, collaboration, growth, and inclusion.

West Hills, CA (Agile) – 2 days remote.

To analyze complex or technically difficult workers’ compensation claims to determine benefits due; to manage 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.

• Analyze and process complex or technically difficult workers’ compensation claims, investigating and gathering information to determine exposure on the claim; manage claims through well-developed action plans to an appropriate and timely resolution.
• Negotiate settlement of claims within designated authority.
• Calculate and assign timely and appropriate reserves to claims; manage reserve adequacy throughout the life of the claim.
• Calculate and pay benefits due; approve and make timely claim payments and adjustments; settle claims within designated authority level.
• Prepare necessary state filings within statutory limits.
• Manage the litigation process; ensure timely and cost‑effective claims resolution.
• Coordinate vendor referrals for additional investigation and/or litigation management.
• Use appropriate cost containment techniques, including strategic vendor partnerships, to reduce overall cost of claims.
• Manage claim recoveries, including subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
• Report claims to the excess carrier; respond to requests of direction in a professional and timely manner.
• Communicate claim activity and processing with the claimant and the client; maintain professional client relationships.
• Ensure claim files are properly documented and claims coding is correct.
• Refer cases as appropriate to supervisor and management.

• Perform other duties as assigned.
• Support the organization’s quality program(s).
• Travel as required.

Education & Licensing

Bachelor's degree from an accredited college or university preferred. Professional certification 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.
• 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…