Claims Examiner III

Tristar Insurance•Rancho Cordova, CA

6d•$80,000 - $99,000•Hybrid

About The Position

This will be a permanent Floating Examiner position to cover open desks due to Vacations, Leaves of Absence, new business onboarding, increased pending inventories, Auditing, etc. At the Direction of the Claims Supervisor and/or Manager, under minimal supervision, manages all aspects of Workers’ Compensation claims (complex, litigated, non-disabling) claims from inception to conclusion within established authority and guidelines. The position requires considerable interaction with clients, claimants, medical providers, Attorneys, vendors, nurses and Vocational Case Managers, and other TRISTAR staff.

Requirements

Education/Experience: 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 people at all levels in the business environment.
Ability to independently and effectively manage very complex claims.
Proficient in Word and Excel (preferred).
California Self-Insurance Certificate

Nice To Haves

Proficient in Word and Excel (preferred).

Responsibilities

Effectively manages a Temporary caseload of Workers’ Compensation claim files, including very complex and litigated claims.
Initiates and conducts investigations in a timely manner.
Determines compensability of claims and administer 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.
Communicate with claimants, attorneys, providers and vendors regarding claims issues.
Work in an organized and proactive manner.
Computes and set reserves within Company guidelines.
Settles and/or finalize 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.
Identify and review claims for Apportionment assignment.
Identify and investigate subrogation potential and pursue recovery.
Identify claim standard criteria for excess reporting and reimbursement.
Assist with State Audit and reporting responses.
Mentors less experienced Examiners
Other duties as assigned and including claims management of other jurisdictional workers’ comp claims.
Adheres to all TRISTAR company policies and procedures.
Essential job function.