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PMA Companies · 2 months ago

Account Claims Representative II

BLUE BELL, PA, 19422, United States

Full-time

Onsite

Mid Level

PMA Companies is a provider of claims management services, and they are seeking an Account Claims Representative II to manage complex Workers Compensation Claims. The role involves investigating, evaluating, and resolving claims while ensuring compliance with legal statutes and company guidelines.

Financial ServicesInsurance

Work & Life Balance

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

Qualification

Workers Compensation ClaimsClaims InvestigationCustomer ServiceNegotiation SkillsEffective Communication

Required

Knowledge of Workers Compensation Claims

Ability to independently investigate, evaluate and resolve assigned claims of a more complex nature

Ability to administer and resolve highest risk management expectations claims in a timely manner

Knowledge of legal statutes, policy provisions, and company guidelines

Ability to promptly investigate all assigned claims with minimal supervision

Ability to determine coverage, compensability, potential for subrogation recovery, and second injury fund (when applicable)

Ability to alert Supervisor and Special Investigations Unit to potentially suspect claims

Ability to ensure timely denial or payment of benefits in accordance with jurisdictional requirements

Ability to establish appropriate reserves with documented rationale and maintain and adjust reserves over the life of the claim

Ability to negotiate claims settlements within granted authority

Ability to establish and implement appropriate action plans for case resolution including medical and disability management, litigation management, negotiation and disposition

Ability to work collaboratively with PMA nurse professionals to develop and execute return to work strategies

Ability to select and manage service vendors to achieve appropriate balance between allocated expense and loss outcome

Ability to maintain 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

Ability to communicate effectively, verbally and in writing with internal and external parties on a wide variety of claims and account issues

Ability to provide a high degree of customer service to clients, including face to face interactions during claims reviews, stewardship meetings and similar account-specific sessions

Ability to authorize treatment based on the practiced protocols established by statute or the PMA Managed Care department

Ability to 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

Knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work