Claims Specialist - Workers Compensation - De Witt, NY

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Claims Specialist - Workers Compensation

#4893

Multiple Locations

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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 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.

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Requirements:

Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required

CA experience is required; AZ experience is a plus

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%.

Alternate Location(s)

Albany, New York, United States

Buffalo, New York, United States

De Witt, New York, United States

Rochester, New York, United States

Saratoga Springs, New York

Utica, New York, United States

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Who can apply

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