Claims Examiner III (Hybrid)

Tristar Insurance • Concord, CA

131d • $90,000 - $100,000

About The Position

The Claims Examiner III position involves investigating, evaluating, disposing, and settling moderately complex to complex/high exposure claims. This includes determining coverage, compensability, and responsibility, as well as setting proper reserves. The role requires independent analysis of claim exposure and the development of action plans to mitigate and settle claims, while ensuring compliance with corporate policies and legal requirements.

Requirements

• High School Diploma or GED required; Bachelor’s degree in related field strongly preferred.
• Three (3) to five (5) years of Workers’ Compensation Claims administration experience required.
• Demonstrated experience with complex, high-exposure, and litigated WC claims.
• Appropriately licensed and/or certified in all States in which claims are handled.
• Bilingual Spanish is a plus.
• Ability to work in a fast-paced, high-stress environment.
• Strong analytical, critical thinking, and problem-solving skills.
• Effective verbal and written communication skills.
• Excellent planning, organizing, and negotiation skills.
• Attention to detail.
• Proficiency with Microsoft Office applications and claims administration software.

Nice To Haves

• Multi-Jurisdiction experience.
• Good interpersonal skills and ability to work within a team environment.
• Ability to handle multiple priorities simultaneously.
• Ability to work independently.

Responsibilities

• Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies.
• Independently analyzes claim exposure and determines a proper plan of action.
• Interacts with injured workers, client contacts, and attending physicians.
• Coordinates with disability and leave examiners for non-occupational benefits.
• Prepares and issues notices in accordance with mandated requirements.
• Establishes and maintains proper reserving throughout the life of the claim.
• Identifies subrogation potential and pursues reimbursement.
• Complies with carrier excess reporting and threshold requirements.
• Coordinates medical treatment for injured workers.
• Understands Medicare reporting requirements related to Workers’ Compensation claims.
• Facilitates early return to work through various work options.
• Manages all medical aspects of a claim file.
• Refers files for task management assignments to approved vendors.
• Monitors status and quality of work performed.
• Serves as a liaison between medical providers, employees, legal professionals, clients, and vendors.
• Independently manages claims in litigation with regular communication with defense counsel.
• Enters and maintains accurate information in the claims management system.
• Communicates action plans and presents plans for claim resolution.
• Meets with clients to discuss ongoing claims.
• Controls expenses on all Workers’ Compensation claims.
• Mentors first-level WC Examiners.
• Performs other duties as assigned.

Benefits

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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 501-1,000 employees