Claims Representative - Workers Compensation - Boise, ID

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.

#LI-Remote

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


• Must reside in Idaho, USA


• California jurisdiction experience required; OR, ID, NV, and UT 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%.