Claims Resolution Specialist

1 week ago


San Jose, California, United States PMA Companies Full time

Job Summary: As a Claims Resolution Specialist at PMA Companies, you will play a vital role in investigating and resolving complex Workers Compensation claims independently. Your primary goal will be to achieve the best possible outcomes while managing risks effectively.

Responsibilities:

  • Investigation and Evaluation: Conduct thorough investigations into assigned claims, including complex cases, with minimal supervision. Determine coverage, compensability, potential for subrogation recovery, and second injury fund involvement.
  • Case Management: Ensure timely denial or payment of benefits in accordance with jurisdictional requirements. Establish and adjust reserves with documented rationale to reflect changes in exposure.
  • Negotiation and Settlement: Negotiate claims settlements within granted authority. Implement action plans for case resolution, including medical and disability management.
  • Collaboration and Communication: Work collaboratively with PMA nurse professionals to develop return-to-work strategies. Select and manage service vendors to achieve balance between allocated expense and loss outcome.
  • Knowledge and Compliance: Maintain knowledge of CA jurisdictional requirements and applicable case law. Communicate effectively with internal and external parties on claims and account issues.
  • Customer Service: Provide high-level customer service to clients. Authorize treatment based on practiced protocols established by statute or PMA Managed Care department.

Requirements:

  • Education and Experience: Bachelor's degree and/or four or more years of equivalent work experience in an insurance-related industry required. CA jurisdiction experience is essential.
  • Certifications and Licenses: Associate in Claims (AIC) Designation or similar professional designation desired. License required or ability to obtain license within 90 days of employment in mandated states.
  • Skills and Knowledge: Familiarity with medical terminology and/or Workers' Compensation. Working knowledge of Workers Compensation regulations. Strong organizational, critical thinking, and communication skills. Computer literacy, including working knowledge of MS Office Product Suite.

Estimated Salary Range: $65,000 - $85,000 per year, depending on location and experience.



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