Claims Examiner

Title: Claims Examiner

Location: Virtual, US

Duration: 6 Month of Contract Possible Extension

Client: Sedgwick

Job ID: 1177555

Rate: $35/hour on W2

Full Description:

· 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.

· 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.

· Supports the organization's quality program(s).

Qualifications:

· Bachelor's degree from an accredited college or university preferred

· Professional certification as applicable to line of business preferred

· Must have license in FL and NC, as well as other Southeast states; Needs "working knowledge" of these states’ rules/regs.

· At least 5 years’ experience, excellent investigation skills, knowledge of EDI transmissions, fast paced environment

· 5 years of claims management experience or equivalent combination of education and experience required

· 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

Strong organizational skills:

· Good interpersonal skills

· Excellent negotiation skills

· Ability to work in a team environment

· Ability to meet or exceed Service Expectations

Job Type: Contract

Pay: Up to $35.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Experience:

• Claims Management: 5 years (Required)
• investigation: 2 years (Preferred)
• EDI transmissions: 2 years (Preferred)

Work Location: Remote

Salary : $35 - $0