Claims Specialist

externalpmacompanies; Plano (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

externalpmacompanies is seeking a claims professional to independently investigate, evaluate and resolve high-complexity workers' compensation claims in Texas. The role focuses on timely decisions, reserves, and settlements with strong attention to regulatory requirements.

The candidate should have a bachelor's degree or equivalent insurance experience, familiarity with medical terminology, and the ability to travel up to 10% for state-specific needs.

Qualifications

• Bachelor's degree or equivalent work experience in insurance required (TX experience preferred).
• Experience handling claims in AR, OK, CO, and LA or willingness to learn jurisdictions.
• Familiarity with medical terminology and workers' compensation regulations is preferred.

Responsibilities

• Investigate and evaluate assigned complex workers' compensation claims.
• Determine coverage and compensability, reserves, and potential subrogation opportunities.
• Negotiate settlements within authority and coordinate with medical professionals for return-to-work strategies.
• Communicate effectively with internal and external parties and maintain thorough documentation.

Skills

Critical thinking

Decision making

Communication skills

Organizational skills

Customer service

Attention to detail

Time management

MS Office

Excel

Word

Education

Bachelor's degree

AIC designation or similar

Tools

MS Office

Excel

Word

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 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 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
• TX experience is required
• Experience handling claims in AR, OK, CO, and LA is preferred, or the ability and willingness to learn preferred jurisdictions.
• 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%.