Investigates, evaluates, and resolves complex workers compensation claims. Determines coverage and compensability, manages reserves, negotiates settlements, coordinates medical and return-to-work strategies, oversees vendors, and ensures compliance with jurisdictional requirements. Provides client service, communicates with internal and external stakeholders, and maintains accurate claim documentation.
Job Summary & Responsibilities
As a member of our Claims team, utilize your knowledge of Workers Compensation Claims to independently investigate, evaluate and resolve assigned claims of a more complex nature in order to achieve appropriate outcomes. In this position you will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statues, policy provisions, and company guidelines.
Responsibilities:
- Promptly investigates all assigned claims with minimal supervision, including those of a more complex nature
- Determines coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
- Alerts Supervisor and Special Investigations Unit to potentially suspect claims
- Ensures timely denial or payment of benefits in accordance with jurisdictional requirements
- Within granted authority, establishes appropriate reserves with documented rationale, maintains and adjusts reserves over the life of the claim to reflect changes in exposure
- Negotiates claims settlements within granted authority
- Establishes and implements appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
- Works collaboratively with PMA nurse professionals to develop and execute return to work strategies
- Selects and manages service vendors to achieve appropriate balance between allocated expense and loss outcome
- Demonstrates technical proficiency through timely, consistent execution of best claim practices
- Communicates effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
- Provides a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
- Authorizes treatment based on the practiced protocols established by statute or the PMA Managed Care department
- Assists PMA clients by suggesting panel provider information in accordance with applicable state statutes.
- Target salary range - $70,000 - $85,000
- Demonstrate commitment to Company’s 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.
#LI-Remote
Preferred Qualifications- Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required.
- California jurisdiction experience
- 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
- Familiarity with medical terminology and/or Workers' Compensation
- Working knowledge of Workers Compensation regulations, preferably jurisdiction-specific
- 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 gained through previous work experience
- 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%.
- Remote position
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