Bachelor's degree or 4+ years of equivalent insurance experience required
3-5 years handling lost time workers compensation claims, specifically in California jurisdiction
Associate in Claims (AIC) designation or similar preferred
Active license required or ability to obtain within 90 days in mandated states
Familiarity with medical terminology and Workers' Compensation
Strong organizational skills with ability to manage multiple tasks independently
Proven critical thinking and decision-making skills with attention to detail
Responsibilities
Investigate assigned claims independently, focusing on complex cases
Determine coverage, compensability, and potential for subrogation recovery
Notify Supervisor and Special Investigations Unit of suspicious claims
Ensure timely denial or payment of benefits per jurisdictional requirements
Establish and adjust reserves throughout the claim's lifecycle
Negotiate settlements with client approval
Develop and implement action plans for case resolution, including medical and litigation management
Collaborate with PMA nurse professionals on return-to-work strategies
Select and manage service vendors for optimal expense and loss outcomes
Maintain knowledge of jurisdictional requirements and applicable case law
Execute best claim practices consistently and timely
Communicate effectively with internal and external parties regarding claims
Provide high-level customer service during claims reviews and meetings
Authorize treatment based on established protocols
Assist clients with panel provider information per state statutes
Benefits
Remote work flexibility
Opportunities for professional development and certifications
Supportive team environment with collaboration across departments
Access to resources for maintaining compliance and best practices
Commitment to ethical standards and business conduct
Full 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 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.
#LI-Remote
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 California 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%.
