Sr Claims Specialist

externalpmacompanies; Greenville (MS); On-site; USD 60,000 - 80,000; Full time

Job summary

externalPMAC Companies is seeking an experienced Claims professional in Mississippi to independently investigate and resolve complex workers' compensation claims. You will determine coverage, potential for subrogation, and reserves while coordinating with internal teams to ensure timely benefit decisions.

The role requires 3–5 years of WC claims experience, a Bachelor’s degree or equivalent insurance experience, and the ability to travel up to 10%.

Qualifications

• Bachelor's degree or four+ years' insurance experience required.
• 3-5 years' experience handling lost-time workers' comp claims.
• License required or obtainable within 90 days for mandated states.
• Familiarity with medical terminology and Workers' Compensation.
• Strong organizational skills and independent work ability.
• Critical thinking with attention to detail; good judgment.
• Strong verbal and written communication; customer service oriented.
• MS Office proficiency (Word, Excel, PowerPoint).
• Ability to travel for business (<10%).

Responsibilities

• Investigate assigned claims with minimal supervision.
• Determine coverage, compensability, and subrogation potential.
• Alert Supervisor to potentially suspect claims.
• Ensure timely denial or payment of benefits per jurisdiction.
• Establish and adjust reserves with rationale.

Skills

Investigative skills

Analytical thinking

Communication skills

Time management

Travel readiness

Education

Bachelor's degree or equivalent insurance experience

AIC designation (desirable)

Tools

MS Office

Job description

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 NC, SC and MS 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
• 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%.