Sr. Claims Specialist

PMA Companies; Camp Hill (Cumberland County); On-site; USD 60,000 - 90,000; Full time

Job summary

PMA Companies in Camp Hill, PA seeks a claims professional to independently investigate, evaluate, and resolve highly complex workers' compensation claims. This role handles highest risk management expectations to ensure timely outcomes in line with statutes and company guidelines.

Responsibilities include reserving, settlement negotiations, and coordinating with PMA nurse professionals on return-to-work plans.

Qualifications

• Bachelor's degree or 4+ years equivalent work experience in insurance required.
• 3-5 years' experience handling lost time workers' compensation claims; MD, DC, WV and PA jurisdiction experience preferred.
• Active license required or ability to obtain license within 90 days in mandated states.
• Knowledge of medical terminology and Workers' Compensation.

Responsibilities

• Investigate assigned claims with minimal supervision, including complex cases.
• Determine coverage, compensability, subrogation potential, and second injury fund applicability.
• Alert Supervisor and SIU to potentially suspect claims.
• Ensure timely denial or payment of benefits per jurisdictional requirements.
• Establish reserves with documented rationale and adjust over the life of the claim.
• Negotiate settlements with client approval.
• Develop action plans for case resolution including medical, disability, litigation management and disposition.
• Collaborate with PMA nurse professionals on return-to-work strategies.
• Select and manage vendors to balance expenses and loss outcomes.
• Maintain knowledge of state requirements and applicable case law.

Skills

Analytical thinking

Strong organizational skills

Critical thinking

Verbal and written communication

Customer service

Education

Bachelor's degree or 4+ years equivalent experience

Tools

MS Office (Word, Excel, PowerPoint)

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.

Requirements:

• 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 MD, DC, WV and PA jurisdiction is required
• 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
• 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
• 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%.

Alternate Location(s)

Hunt Valley , Maryland , United States

Charleston , West Virginia , 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.