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

• Performs other duties as assigned.
• Supports the organization's quality program(s).
• Travels as required.

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.