Medical claims examiner job description

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Claims Examiner - Medical Only

IF YOU CARE, THERE'S A PLACE FOR YOU HERE

For a career path that is both challenging and rewarding, join Sedgwick's talented team of 27,000 colleagues around the globe. Sedgwick is a leading provider of technology-enabled risk, benefits and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. Whether they have a workplace injury, suffer property or financial loss or damage from a natural or manmade disaster, are involved in an auto or other type of accident, or need time away from work for the birth of a child or another medical situation, we are here to provide compassionate care and expert guidance. Our clients depend on our talented colleagues to take care of their most valuable assets-their employees, their customers and their property. At Sedgwick, caring counts®. Join our team of creative and caring people of all backgrounds, and help us make a difference in the lives of others.

For more than 50 years, Sedgwick has been helping employers answer virtually every question there is about workers' compensation. We have experience in nearly every type of industry and region and provide the industry's broadest range of programs and services.


PRIMARY PURPOSE
: To analyze reported lower-level workers compensation claims to determine benefits due; and to ensure ongoing adjudication of claims within company standards and industry best practices.


ESSENTIAL FUNCTIONS and RESPONSIBILITIES


Adjusts medical-only claims and minor lost-time workers compensation claims under close supervision. Supports other claims representatives, examiners and leads with larger or more complex claims as necessary. Processes workers compensation claims determining compensability and benefits due; monitors reserve accuracy, and files necessary documentation with state agency. Communicates claim action/processing with claimant, client and appropriate medical contact. Ensures claim files are properly documented and claims coding is correct. May process routine payments and prescriptions and status reports for lifetime medical claims and/or defined period medical claims. Maintains professional client relationships.


ADDITIONAL FUNCTIONS and RESPONSIBILITIES


Performs other duties as assigned. Supports the organization's quality program(s).


QUALIFICATION



Education & Licensing

High school diploma or GED required. Licenses as required.


Experience

One (1) year of general office experience or equivalent combination of education and experience required. Claims industry experience preferred.


Skills & Knowledge


Excellent oral and written communication 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


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.

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