Job Information
Sedgwick Claims Adjuster- Multi Line (Bilingual - Spanish/English) in San Juan, Puerto Rico
Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flexibility and time for all the things that are important to you. It’s an opportunity to do something meaningful, each and every day. It’s having support for your mental, physical, financial and professional needs. It means sharpening your skills and growing your career. And it means working in an environment that celebrates diversity and is fair and inclusive.
A career at Sedgwick is where passion meets purpose to make a positive impact on the world through the people and organizations we serve. If you are someone who is driven to make a difference, who enjoys a challenge and above all, if you’re someone who cares, there’s a place for you here. Join us and contribute to Sedgwick being a great place to work.
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Claims Adjuster- Multi Line (Bilingual - Spanish/English)
PRIMARY PURPOSE : To analyze mid- and higher-level multi-product line 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.
ESSENTIAL FUNCTIONS and RESPONSIBILITIES
Manages mid-level claims by gathering information to determine exposure; assesses damages, assigns reserve values to claims, making claims payments as necessary, and settling claims up to designated authority level.
Assesses and resolves claims within evaluation.
Approves and processes assigned claims, determines benefits and damages due, and manages action plan pursuant to the claim or client contract.
Manages subrogation of claims, secures and disposes of salvage, and negotiates settlements.
Communicates claim action with claimant, insured, client and agent or broker as appropriate.
Ensures claim files are properly documented and claims coding is correct.
May process complex 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.
Travels as required.
QUALIFICATIONS
Education & Licensing
Bachelor's degree from an accredited college or university preferred.
Experience
Four (4) years of claims management experience or equivalent combination of education and experience required.
Skills & Knowledge
Subject matter expert of appropriate insurance principles and laws for line-of-business handled, recoveries offsets and deductions, claim and disability duration, cost containment principles including medical management practices and Social Security and Medicare application procedures 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
Excellent negotiation 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.
OBJETIVO PRINCIPAL: analizar los reclamos de nivel medio y alto de líneas de varios productos para determinar beneficios debidos; asegurar la resolución continua de reclamos, de acuerdo con los estándares de la empresa y las mejores prácticas del sector; identificar la subrogación de reclamos y negociar acuerdos.
FUNCIONES y RESPONSABILIDADES ESENCIALES
Administrar reclamos de nivel medio a través de la recopilación de información para determinar la exposición; evaluar los daños, asignar valores de reserva a los reclamos y pagar los reclamos según sea necesario; y dirigir los reclamos a la autoridad del nivel correspondiente.
Analizar y resolver reclamos mediante una evaluación.
Aprobar y procesar los reclamos asignados, determinar beneficios y daños debidos y llevar a cabo el plan de acción correspondiente al reclamo o al contrato del cliente.
Administrar la subrogación de reclamos, asegurar y gestionar los objetos recuperados y negociar acuerdos.
Comunicar las acciones de reclamo a los interesados, aseguradores, clientes y agentes o corredores según corresponda.
Asegurar que el registro de los reclamos se encuentre correctamente documentado y que sus respectivos códigos son correctos.
Podría tramitar reclamos médicos vitalicios o por tiempo definido que sean complejos e incluyan informes de estado y médicos, así como también las decisiones sobre tratamientos adecuados recomendados mediante una revisión de utilización.
Mantener relaciones profesionales con los clientes.
FUNCIONES y RESPONSABILIDADES ADICIONALES
Llevar a cabo otras tareas que se le asignen.
Viajar según sea necesario.
CALIFICACIONES
Educación y Licencia
Preferiblemente, con título de licenciado de una universidad o un instituto universitario acreditado.
Experiencia
Se requieren cuatro (4) años de experiencia en administración de reclamos o una combinación de educación y experiencia equivalente.
Competencias y conocimiento
Experto en el tema de los principios de seguro correspondientes y las leyes de gestión del área de negocios, compensación de cobros y deducciones, duración de reclamos e incapacidades, principios de contención del gasto, incluidas las prácticas de administración médica y también los trámites de solicitud del Seguro Social y Medicare que requiere el área de negocios.
Excelente comunicación oral y escrita y habilidades de presentación.
Con conocimientos de computación y productos de Microsoft Office.
Competencias analíticas y de interpretación.
Competencias de organización sólidas.
Óptimas habilidades interpersonales.
Excelentes competencias de negociación.
Capacidad para trabajar en equipo.
Capacidad para cumplir y superar las expectativas de servicio.
AMBIENTE LABORAL
Cuando proceda y se considere oportuno, se tendrán en cuenta adaptaciones razonables.
Capacidades Mentales: habilidad para pensar de forma clara y conceptual; excelente criterio; identificar y resolver problemas, análisis y discreción; habilidad para lidiar con el estrés laboral y para trabajar con múltiples prioridades en simultáneo; y capacidad para cumplir con los plazos de entrega.
Capacidades físicas :
- Manejo del teclado de la computadora; disponibilidad para viajar
Capacidades auditivas y visuales : audición, visión y habla
NOTA : La habilitación de seguridad crediticia, confirmada mediante una verificación de antecedentes crediticios, es un requisito para esta posición.
Las declaraciones contenidas en este documento pretenden describir las características generales y el nivel de trabajo que realiza un colega asignado a esta descripción. No pretenden constituir una lista completa de funciones, deberes o variaciones locales. La gerencia podrá, a su criterio, agregar o cambiar las funciones del cargo en cualquier momento.
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.
Taking care of people is at the heart of everything we do. Caring counts
Sedgwick is a leading global provider of technology-enabled risk, benefits and integrated business solutions. Every day, in every time zone, the most well-known and respected organizations place their trust in us to help their employees regain health and productivity, guide their consumers through the claims process, protect their brand and minimize business interruptions. Our more than 30,000 colleagues across 80 countries embrace our shared purpose and values as they demonstrate what it means to work for an organization committed to doing the right thing – one where caring counts. Watch this video to learn more about us. (https://www.youtube.com/watch?v=ywxedjBGSfA)