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Insurance Examiner

Lucas James Talent Partners

This is a Full-time position in Los Angeles, CA posted June 3, 2021.

SENIOR CLAIMS EXAMINER WORKERS COMPENSATION

IF YOU CARE, THERE’S A PLACE FOR YOU HERE
For a career path that is both challenging and rewarding, join Sedgwick’s talented team of 27,000
colleagues around the globe. Sedgwick is a leading provider of technology-enabled risk, benefits and
integrated business solutions. Taking care of people is at the heart of everything we do. Millions
of people and organizations count on Sedgwick each year to take care of their needs when they face a
major life event or something unexpected happens. Whether they have a workplace injury, suffer
property or financial loss or damage from a natural or manmade disaster, are involved in an auto or
other type of accident, or need time away from work for the birth of a child or another medical
situation, we are here to provide compassionate care and expert guidance. Our clients depend on our
talented colleagues to take care of their most valuable assets-their employees, their customers and
their property. At Sedgwick, caring counts®. Join our team of creative and caring people of all
backgrounds, and help us make a difference in the lives of others.

For more than 50 years, Sedgwick has been helping employers answer virtually every question there is
about workers’ compensation. We have experience in nearly every type of industry and region and
provide the industry’s broadest range of programs and services.

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
* 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 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

NOTE: Credit security clearance, confirmed via a background credit check, is required for this
position.

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.
#LI-TS1

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.
*

Job Requirements:

  • 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.