Account Claims Rep II

PMA Companies

Wallingford,CT

12/10/2019

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.


  • Bachelor's degree and/or four or more years of equivalent work experience required in an insurance related industry required
  • (INSERT STATE) jurisdiction experience
  • Associate in Claims (AIC) Designation or similar professional designation desired
  • 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%.

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