Claims Representative - Sedgwick Claims Management Services, Inc.

PRIMARY PURPOSE: To process low level general liability claims to determine benefits due; to ensure ongoing adjudication of claims within company standards and industry best practices; and to identify subrogation of claims and negotiate settlements with general supervision.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

• Processes low level general liability claims by gathering information to determine liability exposure; assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level.
• Develops and coordinates low level general liability claims' action plans to resolution, return-to-work efforts, and approves claim payments.
• Approves and processes assigned claims, determines benefits due, and administers action plan pursuant to the claim or client contract.
• Administers subrogation of claims and negotiates settlements.
• Communicates claim action with claimant and client.
• Ensures claim files are properly documented and claims coding is correct.
• May process low-level lifetime medical and/or defined period medical claims which include state and physician filings and decisions on appropriate treatments recommended by utilization review.
• Maintains professional client relationships.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

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

QUALIFICATION

Education & Licensing
Bachelor's degree from an accredited college or university preferred.

Experience
Two (2) years of claims management experience or equivalent combination of education and experience or successful completion of Claims Representative training required.

Skills & Knowledge

• Developing knowledge of regulations, offsets and deductions, disability duration, medical management practices and Social Security and Medicare application procedure as applicable to line of business
• Excellent oral and written communication, including presentation skills
• PC literate, including Microsoft Office products
• Analytical and interpretive skills
• Strong organizational skills
• Good interpersonal skills
• Ability to work in a team environment
• Ability to meet or exceed Service Expectations

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

NOTE: Credit security clearance, confirmed via a background credit check, is required for this position.

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.