Specialty Operations Claims Examiner III
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 workers compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; and to ensure ongoing adjudication of claims within company standards and industry best practices or client specific requirements. ESSENTIAL FUNCTIONS and RESPONSIBILITIES - Analyzes and processes complex or technically difficult claims by investigating and gathering information to assist employer in determining their position on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
- Works to move claim towards appropriate claim closure which may include referral for settlement evaluation.
- Monitors reserve adequacy throughout the life of the claim if applicable.
- Monitors and reviews benefits due and payment calculations ensuring accuracy.
- Prepares necessary state filings within statutory limits.
- Follows best practice standards in contested claims including outside legal representation.
- 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.
- Participates in claim recoveries including, but not limited to: subrogation, Second Injury Fund recoveries, and Social Security offsets.
- Communicates claim action/processing with appropriate parties including, but not limited to: claimant, client, state agency, managed care organization and appropriate medical contact.
- Ensures claims files are properly documented and claims coding is correct.
- Maintains professional client relationships.
- Coordinates actuarial/settlement issues impacting employers with rate and settlement departments.
- Assesses policy level status of clients; works in coordination with clients' service expectations and assigned service personnel.
- Maintains a quality assurance program to support the total performance management initiative and the delivery of quality claims service consistently.
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
Three (3) years claims management experience required. Skills & Knowledge - In-depth line-of-business knowledge of appropriate insurance principles and laws, recoveries offsets and deductions, and cost containment principles
- Excellent oral and written communication skills, including presentation skills
- PC literate, including Microsoft Office products
- Analytical and interpretive skills
- Strong organizational skills
- Good interpersonal skills
- Ability to work in a team environment
- 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
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
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