Workers Compensation Claims Examiner III

Job Description

Job Description

Job Summary

Workers Compensation Claims Examiner III

TeemaGroup

Full-time

Hybrid | Philadelphia, PA, United States

The Opportunity

You’re the kind of person who is always looking to learn. You want to grow into something greater and you’re looking for an employer encourages and supports your professional development. This is the largest privately held Third party claims administrator in the US.

Responsibilities

• Adjuster will work hybrid

• Effectively manages a caseload of 125 to 150 workers’ compensation files, including very complex claims. *

• Jurisdiction is PA and NJ. *

• Initiates and conducts investigation in a timely manner. *

• Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines. *

• Manages medical treatment and medical billing, authorizing as appropriate. *

• Refers cases to outside defense counsel.  Directs and manages as appropriate. * 

• Communicates with claimants, providers and vendors regarding claims issues. *

• Computes and set reserves within Company guidelines.  Limits are larger than those allowed for Claims Examiner I and Claims Examiner II. *

• Settles and/or finalize all claims and obtains authority as designated. *

• Maintains diary system for case review and documents file to reflect the status and work being performed on the file. *

• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns. *

• Involves TRISTAR loss control staff when appropriate. *

• Adheres to all Company policies and procedures. *

• Conducts file reviews independently. *

• Other duties as assigned.

Education/Experience: Bachelor’s degree in related field (preferred); three (3) 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 ability to convey technical details to claimants, clients and staff.

• Ability to interact with persons at all levels in the business environment.

• Ability to independently and effectively manage very complex claims.

• Proficient in Word and Excel (preferred).