Bilingual Senior Claims Adjuster

4 weeks ago

Roseville, United States PMA Insurance Group Full time

As a member of our claims team, utilize your knowledge of Workers Compensation to independently investigate, evaluate and resolve assigned claims of a more complex nature in order to achieve appropriate outcomes. In this position you will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statues, policy provisions, and company guidelines.

Responsibilities:

* Promptly investigate all assigned claims with minimal supervision, including those of a more complex nature
* Determine coverage, compatibility, potential for subrogation recovery, and second injury fund (when applicable)
* Alert Supervisor and Special Investigations Unit to potentially suspect claims
* Ensure timely denial or payment of benefits in accordance with jurisdictional requirements
* Establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure
* Negotiate claims settlements with client approval
* Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
* Work collaboratively with PMA nurse professionals to develop and execute return to work strategies
* Select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome
* Maintain a working knowledge of jurisdictional requirements and applicable case law for each state serviced
* Demonstrate technical proficiency through timely, consistent execution of best claim practices
* Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
* Provide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
* Authorize treatment based on the practiced protocols established by statute or the PMA Managed Care department
* Assist PMA clients by suggesting panel provider information in accordance with applicable state statutes.
* Demonstrate commitment to Company's Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

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