Claims Examiner III

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Please complete all of the questions, information and sign your application at the end.

This position requires the employee to be bilingual English/ Spanish.

POSITION SUMMARY: Under minimal supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants on the phone, and with management, other Claims Examiners, and other TRISTAR staff in the office; therefore consistently being at work in the office, in a timely manner, is inherently required of this position.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a caseload of 150 to 180 workers' compensation files, including very complex claims.*
• 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.*
• Adheres to all Company policies and procedures.*
• Conducts file reviews independently.*
• Other duties as assigned.

• Essential job function.

Education/Experience: Bachelor's degree in related field (preferred); 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 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).

Other Qualifications:

• SIP Certifications required