Claims Examiner - Workers Compensation

Sedgwick • Raleigh, North Carolina, United States • 1m ago

Claims Examiner – Workers Compensation Jurisdiction:

NC |

Licensing:

Reciprocal Required (REMOTE – Only NC Residents)

Why Join Us

Apply your knowledge and experience to adjudicate complex customer claims in an energetic culture.

Deliver innovative customer-facing solutions to clients across diverse industries.

Be part of a rapidly growing, industry-leading global company.

Leverage our global network of experts for learning and sharing insights.

Take advantage of varied professional development opportunities.

Enjoy flexibility and autonomy in daily work, location, and career path.

Access diverse and comprehensive benefits for mental, physical, financial, and professional needs.

Ideal Candidate Analyze complex or technically difficult workers' compensation claims to determine benefits due; work with high exposure claims involving litigation and rehabilitation; ensure ongoing adjudication of claims within service expectations, industry best practices and client service requirements; identify subrogation opportunities and negotiate settlements.

Primary Purpose of the Role We seek driven individuals embodying empathy, accountability, collaboration, growth, and inclusion.

Essential Responsibilities

Analyze and process complex workers' compensation claims, investigating and gathering information to determine exposures.

Manage claims through action plans to timely resolution.

Negotiate settlements within designated authority.

Calculate and assign timely reserves; manage reserve adequacy.

Calculate and pay benefits due; approve claim payments and adjustments; settle claims within authority.

Prepare necessary state filings within statutory limits.

Manage litigation process; ensure timely and cost-effective resolution.

Coordinate vendor referrals for investigation and litigation management.

Use cost containment techniques, including vendor partnerships, to reduce overall claims cost.

Manage claim recoveries (subrogation, Second Injury Fund, Social Security, Medicare offsets).

Report claims to the excess carrier; respond to requests promptly.

Communicate claim activity with claimant and client; maintain professional relationships.

Ensure claim files are properly documented and coding is correct.

Travel as required.

Qualifications

Bachelor's degree from an accredited college or university preferred; professional certification preferred.

Five (5) years of claims management experience or equivalent education and experience.

Subject matter expertise in insurance principles, recoveries, offsets, claim duration, cost containment, and related procedures.

Excellent oral and written communication, including presentation skills.

PC literate, including Microsoft Office.

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 Reasonable accommodations considered where applicable.

Mental Clear and conceptual thinking; excellent judgment, troubleshooting, problem solving, analysis, and discretion; handle work-related stress; manage multiple priorities and deadlines.

Physical Computer keyboarding; travel as required.

Auditory/Visual Hearing, vision, and speaking skills.

Benefits

Flexible work schedule.

Referral incentive program.

Opportunity to work in an agile environment.

Career development and promotional growth opportunities.

Diverse and comprehensive benefits: medical, dental, vision, 401(k) on day one.

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

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