Senior Complex Workers' Comp Claims Specialist

PMA Companies; Roseville (CA); On-site; USD 85,000 - 120,000; Full time

Job summary

PMA Companies in Roseville, CA, is seeking an experienced Workers' Compensation Claims professional to independently investigate, evaluate, and resolve highly complex claims, ensuring timely outcomes in compliance with state statutes and company guidelines.

The role emphasizes collaboration with PMA nurses, reserve management, settlements, subrogation checks, and service vendor oversight to balance cost and outcomes while maintaining strong client communication.

Qualifications

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry.
• California jurisdiction experience
• 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%.

Responsibilities

• Prompts 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
• 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 New York 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.

Skills

Organizational skills

Verbal & Written communication

Analytical thinking

Customer service

Negotiation

Education

Bachelor's degree

AIC designation

Tools

MS Office (Word, Excel, PowerPoint)

Job description

PMA Companies in Roseville, CA, is seeking an experienced Workers' Compensation Claims professional to independently investigate, evaluate, and resolve highly complex claims, ensuring timely outcomes in compliance with state statutes and company guidelines.

The role emphasizes collaboration with PMA nurses, reserve management, settlements, subrogation checks, and service vendor oversight to balance cost and outcomes while maintaining strong client communication.