PMA Companies
Claims Specialist - Workers Compensation
PMA Companies, San Francisco, California, United States, 94199
Workers Compensation Claims Adjuster II - California
Join PMA Companies as a
Workers Compensation Claims Adjuster II
in California. In this role you will 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. You will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statutes, 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.
Within granted authority, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure.
Negotiate claims settlements within granted authority.
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 an appropriate balance between allocated expense and loss outcome.
Maintain a working knowledge of New York 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.
Requirements
Bachelor's degree and/or four or more years of equivalent work experience required in an insurance-related industry.
CA jurisdiction license and experience required.
SIP certification preferred; ability to obtain required.
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 detail.
Compensation PMA provides applicants with the anticipated wage range for this position in compliance with state regulations. The wage range is $71,300 to $82,600. Wage ranges are based on national market data and may cover a wide range of geographies. Applicants may be paid above, within, or below this range based on a variety of factors.
Seniority Level Mid-Senior level
Employment Type Full-time
Job Function Finance and Sales
Industry Insurance
Location San Francisco, CA
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Workers Compensation Claims Adjuster II
in California. In this role you will 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. You will administer and resolve highest risk management expectations claims in a timely manner in accordance with legal statutes, 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.
Within granted authority, establish appropriate reserves with documented rationale, maintain and adjust reserves over the life of the claim to reflect changes in exposure.
Negotiate claims settlements within granted authority.
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 an appropriate balance between allocated expense and loss outcome.
Maintain a working knowledge of New York 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.
Requirements
Bachelor's degree and/or four or more years of equivalent work experience required in an insurance-related industry.
CA jurisdiction license and experience required.
SIP certification preferred; ability to obtain required.
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 detail.
Compensation PMA provides applicants with the anticipated wage range for this position in compliance with state regulations. The wage range is $71,300 to $82,600. Wage ranges are based on national market data and may cover a wide range of geographies. Applicants may be paid above, within, or below this range based on a variety of factors.
Seniority Level Mid-Senior level
Employment Type Full-time
Job Function Finance and Sales
Industry Insurance
Location San Francisco, CA
#J-18808-Ljbffr