Claims Representative, Auto | PIP | Remote | NY Lic

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

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PRIMARY

PURPOSE:

To evaluate auto claims involving injured parties and manage first party medical treatment to determine eligibility under a personal injury protection and/or medical payment benefits.

• Reviews claims to determine the nature of the medical loss and provides explanation of coverage.
• Researches policy contract and interprets policy language to make coverage decisions based on 1st party medical coverage.
• Assesses medical treatment, evaluates medical bills, and initiates or reviews potential fraud investigations.
• Interprets medical records regarding injuries and addresses ongoing and continuous treatment for claimant.
• Identifies claim exposures and establishes reserves or adjust reserves accordingly on assigned files.
• Ensures claim files are properly documented and correctly coded based on the policy.
• Documents all claim activity and workflow accurately throughout the life of the claim in accordance with standard operating procedures.
• Provides effective and timely communication to client, claimants, medical providers, attorney offices, and vendors.
• Negotiates resolution of claims and makes payments within authority.
• Performs other duties as assigned.
• Supports the organization's quality program(s).

Education & Licensing

• Bachelor's degree from an accredited college or university preferred.
• State adjuster licenses required.

Experience

Three (3) years of Personal Injury Protection (PIP), medical payment and/or workers compensation or equivalent combination of education and experience, nursing experience a plus.

• Knowledge of medical terminology and appropriate application of deductibles and limits
• Familiarity with Bodily Injury (BI)/Casualty adjusting
• Oral and written communication skills
• Detailed oriented
• PC literate, including Microsoft Office products
• Strong negotiation skills
• Good interpersonal and customer skills
• Good organization skills
• Good time management skills with the ability to multi-task
• Ability to work independently and 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.

For the jurisdiction noted in this job posting only, the range of starting pay for this role is $55,000-$60,000.

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.

• medical
• dental
• vision
• 401k and matching
• PTO
• disability and life insurance
• employee assistance
• flexible spending or health savings account
• other additional voluntary benefits

The statements contained in this document are intended to describe the general nature and level of…