Workers Compensation Claims Examiner | San Diego or Roseville, CA
Sedgwick, San Diego, CA, United States
Workers Compensation Claims Examiner – San Diego or Roseville, CA
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
Analyze and process complex or technically difficult workers' compensation claims by 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; and settle claims within designated authority level.
Prepare necessary state filings within statutory limits.
Manage 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 for our clients.
Manage claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
Report claims to the excess carrier; respond to requests of 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 claim coding is correct.
Refer cases as appropriate to supervisor and management.
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.
Licensing / Jurisdiction Knowledge : SIP required or must be obtained within one (1) year of employment; California workers compensation jurisdictional knowledge required.
Tackling Care of You
Flexible work schedule.
Referral incentive program.
Career development and promotional growth opportunities.
Diverse and comprehensive benefits offering including medical, dental, vision, 401(k) on day one.
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.
As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $80,000 - $100,000. A comprehensive benefits package is offered including but not limited to medical, dental, vision, 401(k) and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
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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
Analyze and process complex or technically difficult workers' compensation claims by 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; and settle claims within designated authority level.
Prepare necessary state filings within statutory limits.
Manage 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 for our clients.
Manage claim recoveries, including but not limited to: subrogation, Second Injury Fund excess recoveries and Social Security and Medicare offsets.
Report claims to the excess carrier; respond to requests of 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 claim coding is correct.
Refer cases as appropriate to supervisor and management.
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.
Licensing / Jurisdiction Knowledge : SIP required or must be obtained within one (1) year of employment; California workers compensation jurisdictional knowledge required.
Tackling Care of You
Flexible work schedule.
Referral incentive program.
Career development and promotional growth opportunities.
Diverse and comprehensive benefits offering including medical, dental, vision, 401(k) on day one.
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.
As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is $80,000 - $100,000. A comprehensive benefits package is offered including but not limited to medical, dental, vision, 401(k) and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Diego Fair Chance Ordinance, the San Francisco Fair Chance Ordinance, the California Fair Chance Act, and all other applicable laws.
Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
#J-18808-Ljbffr