Claims Representative, Auto | PIP | Remote | NY Lic

Sedgwick; Milwaukee (WI); Teletrabalho; USD 55 000 - 60 000; Tempo integral

Vantagens oferecidas por esta oferta de emprego

Medical insurance

Dental insurance

Vision insurance

401k with matching

PTO

Disability insurance

Life insurance

Employee assistance program

FSAs/HSA

Resumo da oferta

Sedgwick is hiring for a remote senior claims adjuster focused on auto PIP and medical payments. You will evaluate medical treatments, interpret policy language, and determine coverage, while maintaining accurate documentation and reserves. Strong negotiation and communication skills are essential.

Three years of PIP/medical or workers' compensation experience is preferred. State adjuster licenses are required. A Bachelor's degree is preferred, with Medicare/BI knowledge advantageous.

Qualificações

• Bachelor's degree preferred; state adjuster licenses required.
• Three 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 (BI)/Casualty adjusting.
• Excellent oral and written communication, detail orientation, and organizational skills.

Responsabilidades

• Evaluate auto claims involving injured parties and manage first-party medical treatment to determine eligibility under PIP/medical payments.
• Review claims, interpret policy language, and make coverage decisions based on first-party medical coverage.
• Assess medical treatment, review bills, and initiate or review fraud investigations.
• Interpret medical records, monitor ongoing treatment, and address claimant needs.
• Identify claim exposures and establish or adjust reserves.
• Document all claim activity and ensure proper coding and SOP compliance.
• Communicate effectively with clients, claimants, providers, attorneys, and vendors.
• Negotiate resolutions and make payments within authority.
• Support quality programs and perform other duties as assigned.

Conhecimentos

Medical terminology

BI/Casualty adjusting

Oral and written communication

Detail oriented

Microsoft Office

Negotiation skills

Interpersonal skills

Organizational skills

Time management

Team environment

Formação académica

Bachelor's degree

State adjuster licenses

Ferramentas

Microsoft Office

Descrição da oferta de emprego

Seven Hills, OH

Telecommuter FL

Telecommuter OH

Telecommuter WI

Telecommuter NY

Telecommuter NJ

Full time

R80462

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.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• 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).

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

• 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

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

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-$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.

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.

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