Claims Examiner III (Hybrid)

Claims Examiner III (Hybrid)

This will be a permanent Floating Examiner position to cover open desks due to Vacations, Leaves of Absence, new business onboarding, increased pending inventories, Auditing, etc.

At the Direction of the Claims Supervisor and/or Manager, under minimal supervision, manages all aspects of Workers' Compensation claims (complex, litigated, non-disabling) claims from inception to conclusion within established authority and guidelines.

The position requires considerable interaction with clients, claimants, medical providers, Attorneys, vendors, Nurse and Vocational Case Managers, and other TRISTAR staff.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a Temporary caseload of Workers' Compensation claim files, including very complex and litigated claims.
• Initiates and conducts investigations in a timely manner.
• Determines compensability of claims and administers benefits based upon state law and TRISTAR Best Practices for claim handling.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refers cases to outside defense counsel and participates in litigated matters.
• Communicate with claimants, attorneys, providers, and vendors regarding claims issues.
• Work in an organized and proactive manner.
• Computes and sets reserves within Company guidelines.
• Settles and/or finalizes all claims and obtains authority as designated.
• Maintains a diary system for case review and documents file to reflect the status and work being performed on the file, including a plan of action.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns.
• Conducts file reviews as scheduled by the client and management.
• Identify and review claims for the Apportionment assignment.
• Identify and investigate subrogation potential and pursue recovery.
• Identify claim standard criteria for excess reporting and reimbursement.
• Assist with State Audit and reporting responses.
• Mentors less experienced Examiners
• Other duties as assigned and including claims management of other jurisdictional workers' comp claims.
• Adheres to all TRISTAR company policies and procedures.

Essential job function.

EQUIPMENT OPERATED/USED: Computer, 10-key, fax machine, copier, printer, and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire

Qualifications

QUALIFICATIONS REQUIRED:

Education/Experience : Minimum five (5) or more years related experience; or equivalent combination of education and experience.

Knowledge, Skills, and Abilities :

• Technical knowledge of statutory regulations and medical terminology.
• Analytical skills.
• Excellent written and verbal communication skills, including the ability to convey technical details to claimants, clients, and staff.
• Ability to interact with people at all levels in the business environment.
• Ability to independently and effectively manage very complex claims.
• Proficient in Word and Excel (preferred).

Other Qualifications :

California Self-Insurance Certificate

Here are some of the benefits you can enjoy in this role:

• Medical, Dental, Vision Insurance.
• Life and Disability Insurance.
• 401(k) Plan
• Paid Holidays
• Paid Time Off.
• Referral bonus.