Claims Examiner III (Hybrid)

TRISTAR RISK MANAGEMENT•Fresno, CA

3d•$90,000 - $90,000•Hybrid

About The Position

Under general 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. This position is a hybrid, temp-to-hire opportunity. SIP is required for this position.

Requirements

Bachelor’s degree in related field (preferred); and one (1) to five (5) 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 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).
Certification and/or or license as required by State regulation.
Consistently being at work in the office, in a timely manner, is inherently required of this position.
Solve practical problems; variety of variables with limited standardization; interpret instructions.
Arithmetic calculations involving fractions, decimals, and percentages.
Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
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.
Near vision: clarity of vision at 20 inches or less
Stooping
Kneeling
Crouching
Reaching
Standing
Walking
Pushing
Pulling
Lifting
Fingering
Grasping
Talking
Hearing
Feeling
Repetitive Motion
Significant work pace/pressure

Nice To Haves

Proficient in Word and Excel

Responsibilities

Effectively manages a caseload of 150 to 180 workers’ compensation files, including complex claims.
Initiates and conducts claims investigation in a timely manner.
Determines compensability of claims and administers 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 as appropriate.
Monitors legal aspects.
Communicates with claimants, providers, and vendors regarding claims issues.
Computes and sets reserves within Company guidelines. Limits are less than those allowed for Claims Examiner III, but larger than those for Claims Examiner I.
Settles and/or finalizes all claims and obtains authority as designated.
Maintains a diary system for case review and document 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.
Involves TRISTAR loss control staff when appropriate.
Adheres to all Company policies and procedures.
Participates in file reviews, as needed.
Other duties as assigned.