Workers Compensation Claims Examiner II

Workers Compensation Claims Examiner II

Hybrid • Honolulu - Kapolei, HI 96814

Salary Range $70,000.00 - $85,000.00 Salary Level Experienced Position Type Full Time Job Shift Day Education Level High School Diploma or GED Travel Percentage Negligible Category Admin - Clerical

Position Summary

At the direction of the claims supervisor, manages all aspects of indemnity and future medical claims from inception to conclusion within established authority and guidelines. This position requires considerable interaction with clients, claimants, medical providers, vendors, and other TRISTAR staff in the office.

Duties and Responsibilities:

• Effectively manages a caseload of 130 to 150 workers' compensation files, including complex claims.
• Initiates and conducts investigation in a timely manner.
• Determines compensability of claims and administers benefits, based upon state laws/rules 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 sets reserves within company/client guidelines.
• Settles and/or finalizes 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
• Adheres to agreed client handling instructions
• Other duties as assigned.

Essential job function

Equipment Operated/Used: Computer, 10-key, fax machine, copier, printer, phone, and other office equipment.

Special Equipment or Clothing: Appropriate office attire.

Qualifications

Qualifications Required:

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).

Other Qualifications:

Certifications and/or licenses as required by State regulation.

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

• Medical, Dental, Vision, Disability and Life Insurance
• 401(k) plan
• Paid time off
• Paid holidays.

Mental and Physical Requirements

1. Mental Effort a. Reasoning development:

• Follow one- or two-step instructions; routine, repetitive task.
• Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.
• Follow written, verbal, or diagrammatic instructions; several concrete variables.
• Solve practical problems; variety of variables with limited standardization; interpret instructions.
• Logical or scientific thinking to solve problems; several abstract and concrete variables.
• Wide range of intellectual and practical problems; comprehend most obscure concepts.

b. Mathematical development:

• Simple additional and subtraction; copying figures, counting, and recording.
• Add, subtract, multiply, and divide whole numbers.
• Arithmetic calculations involving fractions, decimals, and percentages.
• Arithmetic, algebraic, and geometric calculations.
• Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
• Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

c. Language development:

• Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
• Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
• Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
• Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
• Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

2. Physical Effort a. Physical activity required to perform the job:

• Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
• Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds of force frequently c. Exerting a negligible amount of force constantly to move objects (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).
• Medium work: a. Exerting up to 50 pounds of force occasionally b. Exerting up to 20 pounds of force frequently c. Exerting up to 10 pounds of force constantly to move objects Heavy work: a. Exerting up to 100 pounds of force occasionally b. Exerting up to 50 pounds of force frequently c. Exerting up to 20 pounds of force constantly to move objects Very heavy work: a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects

b. Visual requirements necessary to perform the job:

• Far vision: clarity of vision at 20 feet or more
• Near vision: clarity of vision at 20 inches or less
• Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet
• Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are
• Color vision: ability to identify and distinguish colors
• Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point

2. Physical Effort (cont.) - Frequency

c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):

• Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
• Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
• Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.
• Kneeling: Bending legs at knee to come to a rest on knee or knees.
• Crouchng: Bending the body downward and forward by bending legs and spine