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.
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
Maintains a working knowledge of New York jurisdictional requirements and applicable case law for each state serviced
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.
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.
Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
North Carolina 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%.