Specialty Operations Spec

Company Name:
Sedgwick Claims Management Services, Inc.
Job Title: Specialty Operations Spec
City: Seven Hills
State/Province: Ohio
Position Type: Full Time
Specialty Operations Specialist
Providing both satisfying and challenging work along with a highly professional and friendly work atmosphere, Sedgwick has a strong commitment to its colleagues and its clients. If you are seeking a place where you can do great things for those whose lives you touch while maximizing your own career possibilities, Sedgwick is the place for you. As the largest and most innovative Third Party Administrator in the claims industry and the first and only TPA to receive both recognition as theBest TPA in Americaand the covetedEmployer of Choicedesignation, we invite you to come be a part of our team and,"Claim Your Future."
PRIMARY PURPOSE: To analyze complex or technically difficult workers compensation claims to determine benefits due; to work with high exposure claims involving litigation and rehabilitation; and to ensure ongoing adjudication of claims within company standards and industry best practices or client specific requirements.
Analyzes and processes complex or technically difficult claims by investigating and gathering information to assist employer in determining their position on the claim; manages claims through well-developed action plans to an appropriate and timely resolution.
Works to move claim towards appropriate claim closure which may include referral for settlement evaluation.
Monitors reserve adequacy throughout the life of the claim if applicable.
Monitors and reviews benefits due and payment calculations ensuring accuracy.
Prepares necessary state filings within statutory limits.
Follows best practice standards in contested claims including outside legal representation.
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.
Participates in claim recoveries including, but not limited to: subrogation, Second Injury Fund recoveries, and Social Security offsets.
Communicates claim action/processing with appropriate parties including, but not limited to: claimant, client, state agency, managed care organization and appropriate medical contact.
Ensures claims files are properly documented and claims coding is correct.
Maintains professional client relationships.
Coordinates actuarial/settlement issues impacting employers with rate and settlement departments.
Assesses policy level status of clients; works in coordination with clients' service expectations and assigned service personnel.
Performs other duties as assigned.
Supports the organization's quality program(s).
Education & Licensing
Bachelor's degree from an accredited college or university preferred. Licenses as required. Professional certification as applicable to line-of-business preferred.
Three (3) years claims management experience or equivalent combination of education and experience required.
Skills & Knowledge
In-depth line-of-business knowledge of appropriate insurance principles and laws, recoveries offsets and deductions, and cost containment principles
Excellent oral and written communication skills, including presentation 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
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
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
Additional Information: LI-KN

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