Senior Account Claims Representative - Workers Compensation - Atlanta - job 636577

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 equivalent work experience.


• GA residency required.


• At least 3-5 years experience handling lost time workers' compensation claims in GA is required, additonal jurisdictions a plus.


• Experience working with unbundled claims preferred.


• Associate in Claims (AIC) Designation or similar professional designation desired.


• 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%.