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Senior Claims Specialist

2 months ago

Schaumburg, Illinois, United States PMA Companies Full time
Job Title: Sr. Account Claims Representative

As a key member of our claims team, you will utilize your expertise in Workers Compensation to independently investigate, evaluate, and resolve assigned claims of a more complex nature. Your goal will be to achieve appropriate outcomes while ensuring timely and effective management of claims.

Responsibilities:
  • Investigate 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 an 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 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.
Requirements:
  • 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 IL, MI, KS, WI, and IN 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%.