Worker Compensation Claims Examiner III (Hybrid)

TRISTAR RISK MANAGEMENT•Rancho Cordova, CA

97d•$85,000 - $95,000•Hybrid

About The Position

At the direction of the Claims Supervisor and/or Manager, the Worker Compensation Claims Examiner III manages all aspects of complex and litigated indemnity claims from inception to conclusion within established authority and guidelines. The role involves considerable interaction with clients, claimants, medical providers, attorneys, vendors, nurse and vocational case managers, and other TRISTAR staff. The position is hybrid and based in Rancho Cordova, California.

Requirements

Minimum five or more years of related experience, or an 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 a business environment.
Ability to independently and effectively manage very complex claims.
Licenses as required by jurisdiction.
SIP is required.
Ability to meet the stated mental and physical requirements of the job, including light physical work and the listed vision and activity requirements.

Nice To Haves

Proficiency in Microsoft Word and Excel is preferred.

Responsibilities

Effectively manage a caseload of indemnity claim files, including very complex and litigated claims.
Initiate and conduct investigations in a timely manner.
Determine claim compensability and administer benefits according to state law and TRISTAR best practices.
Manage medical treatment and medical billing, authorizing as appropriate.
Refer cases to outside defense counsel and participate in litigated matters.
Communicate with claimants, attorneys, providers, and vendors about claims issues.
Work in an organized and proactive manner.
Compute and set reserves within company guidelines.
Settle and/or finalize claims and obtain authority as designated.
Maintain a diary system for case review and document file status and work performed, including a plan of action.
Promptly communicate appropriate information to the client to resolve claims efficiently, including injury trends and safety-related concerns.
Conduct 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 claims meeting excess-reporting criteria and seek reimbursement.
Assist with state audit and reporting responses.
Mentor less experienced Examiners.
Perform other assigned duties, including claims management for workers’ compensation claims in other jurisdictions.
Adhere to TRISTAR company policies and procedures.