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.
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 Florida 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%.
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