Claims Representative Personal Injury Protection/Medical Payment - Virginia Beach - job 676168

Sedgwick Claims Management Services, Inc.

Date: 04/08/2021

City: Virginia Beach, Virginia

Employment type: Full-time

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Claims Representative Personal Injury Protection/Medical Payment


For a career path that is both challenging and rewarding, join Sedgwick's talented team of 27,000 colleagues around the globe. Sedgwick is a leading provider of technology-enabled risk, benefits and integrated business solutions. Taking care of people is at the heart of everything we do. Millions of people and organizations count on Sedgwick each year to take care of their needs when they face a major life event or something unexpected happens. Whether they have a workplace injury, suffer property or financial loss or damage from a natural or manmade disaster, are involved in an auto or other type of accident, or need time away from work for the birth of a child or another medical situation, we are here to provide compassionate care and expert guidance. Our clients depend on our talented colleagues to take care of their most valuable assets—their employees, their customers and their property. At Sedgwick, caring counts®. Join our team of creative and caring people of all backgrounds, and help us make a difference in the lives of others.

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.


  • 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).

  • Travels as required.


Education & Licensing

Bachelor's degree from an accredited college or university preferred. State adjuster licenses required.


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


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

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.

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