Claims Specialist - Workers Compensation

PMA Companies; Roseville (CA); Remote; USD 60,000 - 80,000; Full time

Job summary

PMA Companies in the United States is seeking a Claims Specialist for Workers' Compensation. This role focuses on independently investigating and resolving high-risk claims, while coordinating with nurses and vendors to manage outcomes.

Strong analytic and communication skills are essential to assess coverage, liability, and subrogation potential. Responsibilities include timely denial or payment of benefits, reserve management, and collaboration with internal teams to drive appropriate

Qualifications

• Degree or four+ years in an insurance-related role.
• Experience handling workers' compensation claims preferred.
• Competent in medical terminology and regulatory guidelines.

Responsibilities

• Investigates and resolves complex claims with minimal supervision.
• Assesses coverage, compensability, subrogation potential, and second injury fund relevance.
• Negotiates settlements within authority and manages reserves.
• Collaborates with PMA nurse teams on return-to-work strategies.
• Communicates with clients and vendors to support case outcomes.

Skills

Independent investigation

Analytical thinking

Communication skills

MS Office proficiency

Education

Bachelor's degree

Tools

MS Office

Job description

Claims Specialist - Workers Compensation

#4908

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
• 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.

#LI_Remote

Requirements:

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
• CA experience is 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%.
• Salary expectations - $60,000 - $80,000

Alternate Location(s)

Oakland , California , United States

San Jose , California , United States

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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.