Account Claims Rep II

Posted 2 Days Ago
Be an Early Applicant
Nashville, TN
In-Office
Mid level
Insurance
The Role
Investigate, evaluate, and resolve complex Workers Compensation claims, ensuring compliance with legal statutes and company guidelines while providing excellent customer service.
Summary Generated by Built In
Job Summary & Responsibilities

Job Description:

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 New York 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.
Preferred Qualifications

Requirements:

  • Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
  • AL 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
  • Ability to travel for business purposes, approximately less than 10%.

 

Top Skills

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The Company
HQ: Blue Bell, Pennsylvania
1,511 Employees
Year Founded: 1915

What We Do

PMA Companies provides risk management solutions and services, specializing in workers’ compensation and offering property & casualty insurance, in the United States.

Headquartered in Blue Bell, PA, PMA Companies is a member of Old Republic Companies. Old Republic International Corporation (NYSE: ORI) is one of the nation’s 50 largest publicly held insurance organizations.

PMA Companies includes: PMA Insurance Group, specializing in workers’ compensation, and providing other commercial property & casualty insurance products; and PMA Management Corp. and PMA Management Corp. of New England, providing results-driven TPA and Risk Services specializing in workers’ compensation and liability.

We maintain a large client retention rate of 90% or higher and a client satisfaction rate of 96% per an independent survey. At PMA, we still build relationships the "old-fashioned way."​ Our clients know we care. They know we say what we do and do what we say. And they know that they can count on us to deliver tangible value to their business and to work passionately on their behalf.

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