Claims Examiner

PRIMARY PURPOSE: To act as a department subject matter expert by providing guidance to the complex claims team to ensure consistency resolving matters optimally while creating a culture of continual quality improvement destined to elevate the overall claim handling to benefit our stakeholders; to ensure the consistency in the developed targeted solutions, and technical guidance and oversight provided to claims team.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Analyzes and processes complex general liability 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.
• Proactively and strategically manages a complex claim inventory by assessing highly complex claims issues, utilizing jurisdictional expertise, providing oversight, and helping direct the handling to achieve the best possible resolution
• Assesses liability and resolves claims within evaluation.
• 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.
• Receive and review relevant pleadings, medical records and other investigative documents.
• Review and evaluate insurance contract wording and coverage for each assigned claim.
• Discuss claim with appointed panel counsel and establish a comprehensive investigative and litigation management strategy for each claim;
• Manage claims within preexisting litigation protocols and practices;

• Assists the claims team as their subject matter expert to assist in addition to lines of business and key jurisdictions on complex claim issues.
• Articulates and documents clear and concise file notes to allow stakeholders to understand the issues and path to resolution.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travel may be required but would be limited to attending mediations or trials.

Education & Licensing

• J.D. preferred, but not required
• Bachelor's degree from an accredited college or university preferred. Industry designation(s) preferred. Licenses as required for specific jurisdictions.

Experience

• 10+ years of experience of claim experience litigating commercial exposure.

Skills & Knowledge

• Knowledge of California Laws
• California Claims experience
• Experience in reading and interpreting contract and/or policy language
• Ability to obtain and maintain appropriate licensing
• Analytical and interpretive skills
• Ability to manage claims across multiple jurisdictions
• Excellent oral and written communication skills
• PC literate, including Microsoft Office products
• Ability to work in a team environment
• Ability to meet or exceed Service Expectations

WORK ENVIRONMENT Remote.

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.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is ($61,857 - $90,000) +bonus eligible. A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.