Workers Compensation Claims Examiner III

Tristar Insurance•Rancho Cordova, CA

1d•$90,000 - $95,000•Onsite

About The Position

At the direction of the Claims Supervisor and/or Manager, the Workers Compensation Claims Examiner III manages complex and litigated indemnity claims from inception through 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 also handles claims in other workers’ compensation jurisdictions as assigned and mentors less experienced examiners.

Requirements

At least five 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 explain technical details to claimants, clients, and staff.
Ability to interact with people at all levels of the business environment.
Ability to independently and effectively manage very complex claims.
Licenses required by the applicable jurisdiction.

Nice To Haves

Proficiency in Microsoft Word and Excel is preferred.

Responsibilities

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