Senior Workers' Comp Claims Specialist

PMA Companies; New York (NY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

PMA Companies is seeking a Claims Specialist - Workers Compensation to independently investigate, evaluate and resolve high-complexity claims in accordance with legal statutes, policy provisions and company guidelines.

The role involves determining coverage, reserving, negotiating settlements, coordinating return-to-work strategies, and collaborating with PMA nurse professionals to support client interests across multiple jurisdictions.

Qualifications

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
• CA experience is required; AZ experience is a plus
• 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
• Ability to travel for business purposes, approximately less than 10%.

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.

Skills

Attention to detail

Communication skills

Independent work

Travel allowance

Education

Bachelor's degree or equivalent experience

Tools

MS Office (Word, Excel, PowerPoint)

Job description

PMA Companies is seeking a Claims Specialist - Workers Compensation to independently investigate, evaluate and resolve high-complexity claims in accordance with legal statutes, policy provisions and company guidelines.

The role involves determining coverage, reserving, negotiating settlements, coordinating return-to-work strategies, and collaborating with PMA nurse professionals to support client interests across multiple jurisdictions.