Claims Adjuster - Workers Compensation

PMA Companies; Schaumburg (IL); On-site; USD 65,000 - 90,000; Full time

Job summary

PMA Companies is seeking an experienced Workers' Compensation Claims professional to independently investigate, evaluate, and resolve highly complex claims. You will administer and resolve high-risk claims in alignment with statutes, policy provisions, and company guidelines.

You will determine coverage, reserves, and potential subrogation while collaborating with nurses, attorneys, and vendors to drive timely, compliant outcomes.

Qualifications

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry
• License required or ability to obtain license within 90 days of employment in mandated states
• Familiarity with medical terminology and/or Workers' Compensation
• Ability to travel for business purposes, approximately less than 10%

Responsibilities

• Investigate assigned claims promptly with minimal supervision, including complex cases
• Determine coverage, compensability, subrogation potential, and second injury fund applicability
• Alert Supervisor and Special Investigations Unit to potentially suspect claims
• Ensure timely denial or payment of benefits per jurisdictional requirements
• Establish reserves with documented rationale and adjust over the life of the claim
• Negotiate settlements within granted authority
• Develop and implement action plans for case resolution (medical, disability, litigation)
• Coordinate with Lodestar nurse professionals on return-to-work strategies
• Select and manage service vendors to balance expenses and loss outcomes
• Maintain knowledge of jurisdictional requirements and applicable case law
• Communicate effectively with internal and external parties
• Provide high-level customer service during reviews and sessions
• Authorize treatment per Lodestar protocols
• Assist with panel provider information per state statutes
• Uphold Company Code of Conduct and Ethics

Skills

Organizational skills

Critical thinking

Verbal communication

Written communication

Customer service

Education

Bachelor's degree or equivalent

Tools

MS Office (Word, Excel, PowerPoint)

Job description

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 Lodestar 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 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 Lodestar Managed Care department
• Assists Lodestar 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.

Requirements

• Working knowledge of Workers Compensation regulations for MN, WI, IN and IL jurisdiction.
• License preferred.
• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
• 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 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%.

This Company is an Equal Opportunity Employer, and does not discriminate on the basis of race, gender, ethnicity, religion, national origin, age, disability, veteran status, or on any other basis prohibited by law. Information on race, gender and national origin will only be used for statistical and recordkeeping purposes, and will not be used in making any employment decisions. All information provided will be kept separate from your expression of interest. Providing this information is strictly voluntary, and you will not be subjected to any adverse action or treatment if you choose not to provide this information. If you do not choose to answer these questions, we ask that you select "Decline to Identify" for each question. Thank you for your voluntary cooperation.