Workers Compensation Claims Adjuster Ii - California

PMA Companies; A distancia; VES 15.426.000 - 17.872.000; Jornada completa

Descripción de la vacante

A leading insurance provider is seeking a Claims Specialist to independently investigate and resolve workers' compensation claims. The ideal candidate will have a Bachelor's degree or equivalent experience, a CA jurisdiction license, and strong organizational skills. Responsibilities include investigating claims, negotiating settlements, and providing high-quality customer service. This role offers a competitive salary range of $71,300 to $82,600.

Formación

• Bachelor's degree and/or four or more years of equivalent work experience.
• CA jurisdiction license and experience required.
• Familiarity with medical terminology and/or Workers' Compensation.
• Strong organizational skills.
• Proven critical thinking skills.

Responsabilidades

• Investigate and resolve complex claims with minimal supervision.
• Determine coverage and compensability for claims.
• Ensure timely denial or payment of benefits.
• Negotiate claims settlements.
• Communicate effectively with all parties involved.

Conocimientos

Critical thinking

Organizational skills

Communication skills

Educación

Bachelor's degree or equivalent work experience

CA jurisdiction license

Descripción del empleo

Job Description

As a member of our Claims team, utilize your knowledge of Workers Compensation Claims 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 statutes, policy provisions, and company guidelines.

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 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.

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Qualifications

Requirements

• Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
• CA jurisdiction license and experience required
• SIP certification preferred, ability to obtain required
• 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

Compensation

PMA is providing applicants with the anticipated wage range for this position in compliance with state regulations. The wage range for this role is $71,300 to $82,600. Wage ranges are based on national market data and may cover a wide range of geographies. Applicants may be paid above, within or below this range based based on a variety of factors.