Senior Claims Resolution Specialist
4 weeks ago
As a key member of our claims team at PMA Companies, you will utilize your expertise in Workers Compensation to independently investigate, evaluate, and resolve assigned claims of a more complex nature to achieve optimal outcomes.
In this position, you will administer and resolve high-risk management expectations claims in a timely manner in accordance with legal statutes, policy provisions, and company guidelines.
Key Responsibilities:
- 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 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.
Demonstrate commitment to PMA Companies' 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.
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 MA, RI, VT, NH, and CT 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%.
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