Claims Examiner, Workers' Compensation | Southeast Jurisdictions | Remote

Sedgwick Claims Management Services, Inc.

Job Overview

Location

Telecommuter TN

Job Type

Full-time

Full Job Description

📋 Description

• Analyzes and processes complex or technically difficult workers' compensation claims to determine benefits due and manage exposure on claims through well-developed action plans for timely resolution.
• Negotiates settlement of claims within designated authority levels, ensuring compliance with client service requirements and industry best practices.
• Calculates and assigns timely and appropriate reserves to claims, continuously managing reserve adequacy throughout the life of each claim.
• Calculates, approves, and processes timely claim payments and adjustments, ensuring accurate disbursement of benefits due to claimants.
• Prepares and submits all necessary state filings within statutory deadlines and regulatory requirements.
• Manages the litigation process for high-exposure claims, ensuring timely and cost-effective resolution while coordinating with legal vendors and counsel.
• Coordinates vendor referrals for additional investigation, medical management, or litigation support to optimize claim outcomes.
• Implements cost containment techniques through strategic vendor partnerships to reduce overall claim costs for clients.
• Manages claim recoveries including subrogation, Second Injury Fund excess recoveries, and offsets related to Social Security and Medicare.
• Reports claims to excess carriers and responds professionally and promptly to carrier requests and directives.
• Communicates claim activity and processing updates clearly and consistently with claimants and clients to maintain professional relationships.
• Ensures all claim files are accurately documented with correct coding and compliance with internal and regulatory standards.
• Refers complex or high-risk cases to supervisors or management as appropriate for escalation or additional review.
• Supports organizational quality programs and adheres to established service expectations and performance metrics.
• Travels as required to meet job responsibilities, including site visits, meetings, or court appearances related to claims.
• Applies subject matter expertise in workers' compensation insurance principles, laws, recoveries, offsets, deductions, disability duration, and medical management practices.
• Demonstrates excellent oral and written communication skills, including presentation abilities for client and internal stakeholder interactions.
• Maintains proficiency in Microsoft Office products and other PC-based systems used for claims processing and documentation.
• Exhibits strong analytical and interpretive skills to evaluate claim data, identify trends, and make sound adjudication decisions.
• Maintains strong organizational skills to manage multiple priorities, meet deadlines, and handle work-related stress effectively.
• Demonstrates good interpersonal skills and the ability to collaborate within a team environment while upholding professional standards.
• Possesses excellent negotiation skills to resolve claims efficiently and within authorized limits.
• Meets or exceeds established service expectations for claim handling, response times, and client satisfaction.

🎯 Requirements

• Five (5) years of claims management experience or equivalent combination of education and experience
• Professional certification as applicable to workers' compensation line of business preferred
• Licensing in home state required
• Jurisdictional expertise in Southeast States: AL, AR, MS, TN
• Subject matter expertise in workers' compensation insurance principles, laws, recoveries, offsets, and medical management practices
• Proficiency in Microsoft Office products and PC-based claims systems

🏖️ Benefits

• Opportunity to work for a Certified Great Place to Work® and Fortune Best Workplaces in Financial Services & Insurance company
• Remote work arrangement with flexibility for telecommuting
• Career growth opportunities within a global organization of 33,000 colleagues
• Supportive, caring culture focused on work-life balance
• Inclusion in a diverse, equitable, and inclusive workplace
• Consideration for reasonable accommodations as applicable

Skills & Technologies

Remote

Degree Required

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Sedgwick Claims Management Services, Inc.

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About Sedgwick Claims Management Services, Inc.

Sedgwick is a global provider of technology-enabled risk, benefits and integrated business solutions, primarily handling insurance claims, managed care, absence and disability, and productivity management for employers, carriers, and administrators. The company processes millions of claims annually across workers' compensation, property, casualty, disability, and other lines, leveraging analytics and digital platforms to improve outcomes, reduce costs, and enhance customer and employee experiences.

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