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Claims Resolution Specialist
2 months ago
Join PMA Companies as a Sr Claims Representative and take on a challenging role in our claims team. As a member of our team, you will utilize your knowledge of Workers Compensation to independently investigate, evaluate, and resolve assigned claims of a more complex nature.
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 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 FL and GA 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%.
