Claims Examiner III (Hybrid)

Tristar Insurance-posted 3 months ago
$85,000 - $95,000/Yr
Full-time • Mid Level
Rancho Cordova, CA
501-1,000 employees
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The Claims Examiner III position is a hybrid and temp-to-hire opportunity located in Sacramento - Rancho Cordova, CA. This role involves managing all aspects of complex and litigated indemnity claims from inception to conclusion, under the direction of the Claims Supervisor and/or Manager. The position requires considerable interaction with clients, claimants, medical providers, attorneys, vendors, nurse and vocational case managers, and other TRISTAR staff.

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