Account Claims Representative II - CA - PMA Companies

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 statues, 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 CA 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.

* #LI-Remote

* Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required

* CA, AZ, UT, and/or NV jurisdiction experience

* 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

* Strong verbal, written communication skills and customer service skills gained through previous work experience

* Computer literacy, including working knowledge of MS Office Product Suite, i.e. Word, Excel, PowerPoint

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled