Sr. Claims Specialist

PMA Companies•Hunt Valley, MD

5d•Remote

About The Position

As a member of the claims team, the Sr. Claims Specialist independently investigates, evaluates, and resolves assigned Workers’ Compensation claims, including complex and high-risk claims. The role administers claims in a timely manner and in accordance with applicable statutes, policy provisions, and company guidelines. It requires sound judgment, technical proficiency, effective communication, and a high degree of customer service.

Requirements

Bachelor’s degree or at least four years of equivalent work experience in an insurance-related industry.
At least 3–5 years of experience handling lost-time Workers’ Compensation claims.
Past experience with Maryland, District of Columbia, West Virginia, and Pennsylvania jurisdictions.
Active license, or ability to obtain a license within 90 days of employment in mandated states.
Familiarity with medical terminology and/or Workers’ Compensation.
Strong organizational skills and demonstrated ability to work independently and manage multiple tasks simultaneously.
Proven critical-thinking skills, including analysis, judgment, sound decision-making, and attention to detail.
Strong verbal and written communication and customer service skills.
Computer literacy, including working knowledge of Microsoft Office products such as Word, Excel, and PowerPoint.
Ability to travel for business purposes, approximately less than 10%.

Nice To Haves

Associate in Claims (AIC) designation or similar professional designation.

Responsibilities

Promptly investigate assigned claims with minimal supervision, including complex claims.
Determine coverage, compensability, potential subrogation recovery, and second injury fund applicability.
Alert the 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, and maintain and adjust reserves as claim exposure changes.
Negotiate claim settlements with client approval.
Establish and implement action plans for case resolution, including medical and disability management, litigation management, negotiation, and disposition.
Collaborate with PMA nurse professionals to develop and execute return-to-work strategies.
Select and manage service vendors to balance allocated expenses and loss outcomes appropriately.
Maintain 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 about claims and account issues.
Provide customer service to clients, including face-to-face participation in claims reviews, stewardship meetings, and similar account-specific sessions.
Authorize treatment based on protocols established by statute or the PMA Managed Care department.
Assist PMA clients by suggesting panel provider information in accordance with applicable state statutes.
Follow the Company’s Code of Business Conduct and Ethics and apply relevant compliance policies, procedures, standards, and laws in performing the role.