Claims Representative

Telecommuter NY Telecommuter FL Telecommuter TX Telecommuter MA Telecommuter NJ Telecommuter RI Full time

R78061

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. Newsweek Recognizes Sedgwick as America's Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Claims Representative, Auto | PIP **PRIMARY PURPOSE OF THE ROLE:** 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.

**ESSENTIAL RESPONSIBLITIES MAY INCLUDE**

• 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.

**QUALIFICATIONS**

• 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.
• Skills: knowledge of medical terminology and appropriate application of deductibles and limits, familiarity with Bodily Injury (BI)/Casualty adjusting, oral and written communication skills, PC literate, including Microsoft Office products, and organizational skills required.

**TAKING CARE OF YOU**

• Flexible work schedule.
• Referral incentive program.
• Career development and promotional growth opportunities.
• A diverse and comprehensive benefits offering including medical, dental vision, 401K on day one.

**WORK ENVIRONMENT REQUIREMENTS INCLUDE**

Physical: Computer keyboarding Auditory/visual: Hearing, vision and talking Mental: Clear and conceptual thinking ability; excellent judgement and discretion; ability to meet deadlines. _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_ **_$55,000 to $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._ Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

• *If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.**
• *Sedgwick is the world's leading risk and claims administration partner, which helps clients thrive by navigating the unexpected. The company's expertise, combined with the most advanced AI-enabled technology available, sets the standard for solutions in claims administration, loss adjusting, benefits administration, and product recall. With over 33,000 colleagues and 10,000 clients across 80 countries, Sedgwick provides unmatched perspective, caring that counts, and solutions for the rapidly changing and complex risk landscape. For more, see** **sedgwick.com** Sedgwick