Senior Claims Examiner

We are seeking a highly skilled and experienced Claims Representative to join our team at PMA Companies. As a member of our claims team, you will utilize your knowledge of Workers Compensation to independently investigate, evaluate and resolve assigned claims of a more complex nature.

• Promptly investigate all assigned claims with minimal supervision, including those of a more complex nature.
• Determine coverage, compensability, 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.

• Bachelor's degree, or four or more years of equivalent work experience required in an insurance related industry.
• At least 3-5 years' experience handling lost time workers compensation claims required; past experience with Vermont jurisdiction is required.
• Associate in Claims (AIC) Designation or similar professional designation desired.
• Active license required or ability to obtain license within 90 days of employment in mandated states.
• Familiarity with medical terminology and/or Workers' Compensation.
• Strong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneously.
• Proven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to details.
• Strong verbal, written communication skills and customer service skills.
• Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint.
• Ability to travel for business purposes, approximately less than 10%.