Claims Representative, Auto | PIP

Sedgwick; New York (NY); On-site; USD 55,000 - 60,000; Full time

Benefits offered by this job

Flexible schedule

Referral incentive program

Career development

Full benefits (medical, dental, vision

Job summary

Sedgwick in New York is seeking a Claims Representative, Auto | PIP. This role evaluates auto claims involving injured parties and manages first-party medical treatment to determine eligibility under PIP and medical payments.

You will review claims, research policy language, assess medical treatment, document activity, and communicate with clients and providers. A bachelor's degree and state adjuster license are required; 3 years of PIP/medical payment experience is preferred.

Qualifications

• Bachelor’s degree and state adjuster license required.
• Three (3) years of Personal Injury Protection (PIP), medical payment and/or workers compensation experience or equivalent.
• Knowledge of medical terminology and application of deductibles and limits; familiarity with Bodily Injury/Casualty adjusting; strong communication and organizational skills.

Responsibilities

• Reviews claims to determine medical loss and provide explanations of coverage.
• 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 ongoing treatment for claimants.
• Identifies claim exposures and establishes reserves or adjusts reserves.
• Ensures claim files are properly documented and coded per policy.
• Documents all claim activity and workflow as per SOPs.
• Provides timely communication to clients, claimants, medical providers, attorneys, and vendors.
• Negotiates resolution of claims and makes payments within authority.
• Performs other duties as assigned.

Skills

Oral and written communication

Medical terminology

Organizational skills

BI/Casualty adjusting familiarity

Education

Bachelor's degree

Tools

Microsoft Office

Job description

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.