Senior Claims Examiner California Workers’ Compensation Job in Ontario 91710, California US
Senior Claims Examiner California Workers' Compensation
CLAIM YOUR FUTURE AS A GREAT PERFORMER!
Continuing double-digit revenue growth rates and progressive employment practices make Sedgwick Claims Management Services the place where great people can do great things for clients while maximizing their career possibilities. We have earned a reputation for innovation, quality, sustained growth, financial stability and a colleague-friendly work environment. We are proud to have been voted the Best TPA in America for 2005 and 2006, and the first and only Third Party Administrator to receive the coveted Employer of Choice designation. Come be a part of our team and "Claim Your Future."
PRIMARY PURPOSE: To analyze complex or technically difficult claims to determine benefits due; to work with high exposure claims for appropriate line of business (LOB); to ensure ongoing adjudication of claims within company standards, industry best practices and specific client service requirements; and to manage subrogation of claims and negotiate settlements.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
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Analyzes and processes complex or technically difficult 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.
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Assesses liability and resolves claims within evaluation.
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Negotiates settlement of claims up to designated authority level.
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Calculates and assigns timely and appropriate reserves to claims; monitors reserve adequacy throughout the life of the claim.
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Calculates and pays benefits due; approves and makes timely claim payments and adjustments; and settles claims within designated authority level.
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Prepares necessary state filings within statutory limits.
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Manages the litigation process; ensures timely and cost effective claims resolution.
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Coordinates vendor referrals for additional investigation and/or litigation management.
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Uses appropriate cost containment techniques including strategic vendor partnerships to reduce overall cost of claims for our clients.
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Manages claim recoveries, including but not limited to subrogation, Second Injury Fund recoveries and Social Security offsets.
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Reports claims to the excess carrier; responds to requests of directions in a professional and timely manner.
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Communicates claim activity and processing with the ill or injured party and the client; maintains professional client relationships.
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Ensures claim files are properly documented and claims coding is correct.
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Refers cases as appropriate to supervisor and management.
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Supports the organization's quality program(s).
QUALIFICATIONS
Education Licensing
Baccalaureate degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line of business preferred.
Experience
Four (4) years of claims management experience required.
Skills Knowledge
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In-depth knowledge 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 application procedures as applicable to line-of-business
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Excellent oral and written communication, including presentation skills
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PC literate, including Microsoft Office products
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Analytical and interpretive skills
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Strong organizational skills
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Excellent negotiating skills
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Good interpersonal skills
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Ability to work in a team environment
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Ability to meet or exceed Performance Competencies
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.
Sedgwick CMS is an Equal Opportunity Employer
and a
Drug-Free Workplace
Must have California Self-Insurers Certificate (SIP) or AB1262 California Experienced Examiner Designation or currently meet the requirements for designation under AB1262. WCCA, WCCP preferred.
