Senior Account Claims Representative

PMA Companies


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 natureDetermine coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)Alert Supervisor and Special Investigations Unit to potentially suspect claimsEnsure timely denial or payment of benefits in accordance with jurisdictional requirementsEstablish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposureNegotiate claims settlements with client approvalEstablish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and dispositionWork collaboratively with PMA nurse professionals to develop and execute return to work strategiesSelect and manage service vendors to achieve appropriate balance between allocated expense and loss outcomeMaintain a working knowledge of jurisdictional requirements and applicable case law for each state servicedDemonstrate technical proficiency through timely, consistent execution of best claim practicesCommunicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issuesProvide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessionsAuthorize treatment based on the practiced protocols established by statute or the PMA Managed Care departmentAssist 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.Job Requirements:Bachelor's degree, or four or more years of equivalent work experience required in an insurance related industry requiredAt least 3-5 years' experience handling lost time workers compensation claims required; past experience with MI jurisdiction is requiredMust reside in MI however role is fully remote.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' CompensationStrong organizational skills with demonstrated ability to work independently and deal effectively with multiple tasks simultaneouslyProven critical thinking skills that demonstrate analysis/judgment and sound decision making with focus on attention to detailsStrong verbal, written communication skills and customer service skillsComputer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint.Ability to travel for business purposes, approximately less than 10%.SDL2017
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