Claims Specialist - Workers Compensation

PMA Companies; Northern (KY); Hybrid; USD 70,000 - 85,000; Full time

Job summary

PMA Companies is seeking a Claims Specialist - Workers Compensation to autonomously investigate, evaluate and resolve higher-risk workers' compensation claims. You will determine coverage and compensability, manage reserves, negotiate settlements, and coordinate with medical and vendor resources to optimize outcomes.

The role supports remote work with occasional travel and requires a Bachelor’s degree or 4+ years in insurance, plus licensing within 90 days where applicable.

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.
• Working knowledge of Workers' Compensation regulations, preferably jurisdiction-specific.

Responsibilities

• Investigates assigned claims with minimal supervision, including complex cases.
• Determines coverage, compensability, potential for subrogation, and second injury fund considerations.
• Negotiates settlements within granted authority.
• Works with PMA nurse professionals to develop return-to-work strategies.
• Selects and manages service vendors to balance expenses and loss outcomes.

Skills

Investigative skills

Analytical skills

Verbal & written communication

Customer service

MS Office

Education

Bachelor's degree / 4+ years experience

Tools

MS Office

Job description

Claims Specialist - Workers Compensation

#4890

Multiple Locations

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
• 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.

Requirements:

• 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
• 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

Alternate Location(s)

Irvine , California , United States

Oakland , California , United States

Anaheim , California , United States Fresno , California , United States Irvine , California , United States Oakland , California , United States Pasadena , California , United States

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.

EEO is the Law