Claims Examiner III

Responsibilities Effectively manages a caseload of indemnity 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. Communicates with claimants, attorneys, providers, and vendors regarding claims issues. Works 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. Identifies and reviews claims for the Apportionment assignment. Identifies and investigates subrogation potential and pursues recovery. Identifies claim standard criteria for excess reporting and reimbursement. Assists with State Audit and reporting responses. Mentors less experienced Examiners. Other duties as assigned, including claims management of other jurisdictional workers’ comp claims. Adheres to all TRISTAR company policies and procedures. Requirements Minimum five (5) or more years related experience; or equivalent combination of education and experience. 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 persons at all levels in the business environment. Ability to independently and effectively manage very complex claims. Proficient in Word and Excel (preferred). Licenses as required by Jurisdiction. ATS Optimization Keywords Hard Skills Claims Investigation Compensability Determination Medical Billing Management Reserve Computation Subrogation Identification File Review Claims Settlement Diary System Maintenance Excess Reporting Criteria Audit Assistance Soft Skills Organizational Skills Proactive Approach Mentoring Ability Interpersonal Skills Independent Management Certifications & Qualifications Licenses as Required by Jurisdiction #J-18808-Ljbffr