Sr. Claims Representative - Workers Compensation - MD and PA - PMA Companies

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.

* 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 PA, MD, DE, WV and/or DC 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%.

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled