Claims Representative, PIP | Auto | Remote

Claims Representative, Pip | Auto | Remote

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

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 coverages.
• 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.

Additional Functions and Responsibilities :

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 :

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.

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.