Workers Compensation Claims Examiner I / Medical Only

Tristar Insurance•Kapolei, HI

13d•$29 - $36•Onsite

About The Position

At the direction of the Claims Supervisor (or designated CE III Mentor) manages all aspects of Medical Only claims from inception to conclusion within established authority and guidelines. Once proficiency is established, additional responsibilities will include handling minor lost time and future medical claims. This position requires considerable interaction with clients, claimants, Providers, Claims Examiners, and other TRISTAR staff. Therefore, consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

Requirements

Bachelor’s degree in related field (preferred); and one (1) year 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.
Proficient in Word and Excel (preferred).
Certification and/or or license as required by State regulation.
Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables.
Mathematical development: Arithmetic calculations involving fractions, decimals, and percentages.
Language development: Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
Physical activity required to perform the job: Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently c. Exerting a negligible amount of force constantly to move objects (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).
Visual requirements necessary to perform the job: Near vision: clarity of vision at 20 inches or less
Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally): Stooping, Kneeling, Crouching, Reaching, Standing, Walking, Pushing, Pulling, Lifting, Fingering, Grasping, Talking, Hearing, Feeling, Repetitive Motion.

Nice To Haves

Proficient in Word and Excel (preferred).

Responsibilities

Effectively manages a caseload of 150 to 200 workers’ compensation files.
Initiates and conducts claims investigations in a timely manner.
Determines compensability of claims and administers benefits, based upon state laws and rules and in accordance with established Company guidelines.
Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor before authorizing.
Communicates with claimants, providers, and vendors regarding claims issues.
Computes and sets reserves within Company guidelines, up to $.
Finalizes all claims and obtains authority as designated.
Maintains diary system for case review and document file to reflect the status of 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 designated loss control staff when appropriate.
Adheres to all Company policies and procedures.
Participate in file reviews, as needed.
Other duties as assigned include assisting as a claims assistant.