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.
- 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.
- At least 3-5 years' experience handling lost time Workers Compensation claims in PA.
- PA jurisdictional experience required.
- Adjuster licensing in other states a plus.
- Associate in Claims (AIC) Designation or similar professional designation desired.
- Familiarity with medical terminology.
- 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 (post pandemic), less than 10%.
- PMA has multiple offices in PA. Remote and/or hybrid opportunities are available for highly qualified candidates.
- PMA is posting this opportunity based on anticipated new business being written by our TPA in early 2022. Multiple openings are anticipated.
- Attention To Detail
- Claim Processing
- Computer Literacy
- Critical Thinking