Senior Account Claims Representative

PMA Companies; Plano (TX); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading insurance firm is seeking a Claims Investigator in Plano, Texas. This role involves investigating and resolving complex Workers Compensation claims while ensuring compliance with legal requirements. The ideal applicant has a bachelor's degree or relevant work experience and significant experience in handling lost time claims across several jurisdictions. Strong organizational skills and independence are essential. This is a remote position.

Qualifications

• 3-5 years' experience handling lost time workers compensation claims required.
• Familiarity with medical terminology and/or Workers' Compensation.
• Active license required or ability to obtain license within 90 days.

Responsibilities

• Investigate all assigned claims with minimal supervision.
• Ensure timely denial or payment of benefits.
• Negotiate claims settlements with client approval.

Skills

Knowledge of Workers Compensation

Strong organizational skills

Ability to work independently

Education

Bachelor's degree or equivalent work experience

Job description

As a member of our claims team, utilize your knowledge of Workers Compensation 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 investigate all assigned claims with minimal supervision, including those of a more complex nature
• Determine coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)
• Alert Supervisor and Special Investigations Unit to potentially suspect claims
• Ensure timely denial or payment of benefits in accordance with jurisdictional requirements
• Establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure
• Negotiate claims settlements with client approval
• Establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition
• Work collaboratively with PMA nurse professionals to develop and execute return to work strategies
• Select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome
• Maintain a working knowledge of jurisdictional requirements and applicable case law for each state serviced
• Demonstrate technical proficiency through timely, consistent execution of best claim practices
• Communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues
• Provide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions
• Authorize treatment based on the practiced protocols established by statute or the PMA Managed Care department
• Assist 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

Qualifications

• Bachelor's degree, or four or more years of equivalent work experience required in an insurance related industry required
• At least 3-5 years' experience handling lost time workers compensation claims required; past experience with TX, LA, CO, OK and AR jurisdiction is required
• Associate in Claims (AIC) Designation or similar professional designation desired.
• Active 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