Claims Examiner - Workers Compensation

Claims Examiner – Workers Compensation

Dedicated Account | Licensing: TX | Jurisdiction: TX

Primary Purpose of the Role:

We are looking for driven individuals that embody our caring counts model and core values that include empathy, accountability, collaboration, growth, and inclusion.

• Analyze complex or technically difficult workers' compensation claims to determine benefits due.
• Work with high exposure claims involving litigation and rehabilitation.
• Ensure ongoing adjudication of claims within service expectations, industry best practices, and client service requirements.
• Identify subrogation of claims and negotiate settlements.
• 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; and 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 cost containment techniques, including strategic vendor partnerships, to reduce overall cost of claims for clients.
• 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 for directions 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 programs.
• Travel as required.

• Bachelor's degree from an accredited college or university (preferred).
• Required:
  
  Licenses as required; professional certifications applicable to line of business (preferred).
• Required:
  
  Five (5) years of claims management experience or equivalent combination of education and experience.
• Jurisdiction/Licensing:
  Texas.

• Flexible work schedule.
• Referral incentive program.
• Opportunity to work in an agile environment.
• Career development and promotional growth opportunities.
• Diverse and comprehensive benefits offering including medical, dental, vision, and 401(k) on day one.
• Work from home if outside 25-mile radius of Sedgwick office; otherwise hybrid schedule.
• Work environment considers reasonable accommodations when applicable.
• Physical:
  Computer keyboarding, travel as required.
• Auditory/Visual:
  Hearing, vision, and talking.

We offer reasonable accommodations for applicants and employees with disabilities. Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.