Workers' compensation Claims Examiner I / Medical Only

Tristar Insurance•Irving, TX

1d•$24 - $26•Onsite

About The Position

Under close to moderate supervision, manages workers’ compensation medical-only claims from inception through resolution, with total claim exposure not exceeding $10,000 and within assigned authority limits and established company and client guidelines. Coordinates medical treatment, reviews medical billing, maintains accurate claim documentation, and communicates with clients, claimants, employers, medical providers, and TRISTAR staff. Identifies and promptly escalates claims involving potential indemnity benefits, increased exposure, disputed issues, or complexity beyond the medical-only scope.

Requirements

Bachelor’s degree in related field (preferred); and one (1) to three (3) years related experience; or equivalent combination of education and experience.
Working knowledge of applicable workers’ compensation laws, statutory requirements, and medical terminology relevant to medical-only claims.
Ability to investigate and manage medical-only claims within assigned authority and established guidelines.
Analytical skills to evaluate claim information, medical documentation, and billing.
Ability to recognize changes in claim exposure or complexity and seek supervisory guidance promptly.
Strong organizational skills and the ability to maintain a diary system, prioritize tasks, and meet deadlines.
Effective written and verbal communication skills, including the ability to explain claims information clearly to claimants, clients, and staff.
Ability to interact professionally with individuals at all levels of the business environment.
Proficiency in Microsoft Word and Excel preferred.
Certification and/or or license as required by State regulation.
Logical or scientific thinking to solve problems; several abstract and concrete variables.
Arithmetic calculations involving fractions, decimals, and percentages.
Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.
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
Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.
Grasping: Applying pressure to an object with the fingers and palm.
Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts.
Repetitive Motion: Substantial movements (motions) of the wrists, hands, and/or fingers.

Nice To Haves

Proficiency in Microsoft Word and Excel preferred.

Responsibilities

Manages medical-only workers’ compensation claims with total exposure up to $10,000, within assigned authority limits and under close to moderate supervision.
Initiates and conducts timely investigations to gather information needed to evaluate claims.
Determines compensability of medical-only claims in accordance with applicable state laws and company guidelines, seeking supervisory guidance on disputed or unusual matters.
Coordinates and monitors medical treatment and medical billing, providing authorization within assigned authority.
Communicates professionally with claimants, employers, medical providers, and vendors regarding claim status, treatment, billing, and other claims issues.
Calculates, establishes, and adjusts reserves within assigned authority and company guidelines.
Monitors claims for lost time, potential indemnity benefits, increased medical exposure, litigation, or other developments requiring supervisory review or reassignment.
Promptly refers claims exceeding $10,000 in total exposure or the medical-only scope to the supervisor for review and appropriate reassignment.
Maintains a diary system for timely case review and documents claim files to accurately reflect claim status and handling activities.
Promptly communicates relevant information to clients, including injury trends and safety concerns.
Adheres to all company policies, procedures, and applicable client claims handling instructions.
Participate in file reviews as needed.
Performs other duties as assigned.