Workers Compensation Claims Examiner III

Tristar Insurance•Waukesha, WI

9d•$70,000 - $85,000•Onsite

About The Position

Under minimal 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 on time is inherently required of this position.

Requirements

Bachelor’s degree in a related field (preferred); three (3) or more years of 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 conveying 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).
Reasoning development: Solve practical problems; variety of variables with limited standardization; interpret instructions.
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: Light work (Exerting up to 20 pounds of force occasionally, Exerting up to 10 pounds frequently, Exerting a negligible amount of force constantly to move objects).
Visual requirements: Near vision, Mid-range vision, Depth perception, Color vision.
Physical activity necessary: Stooping, Kneeling, Crouching, Reaching, Standing, Walking, Pushing, Pulling, Lifting, Fingering, Grasping.
Communication: Talking, Hearing, Repetitive Motion.

Nice To Haves

Proficient in Word and Excel

Responsibilities

Effectively manages a caseload of 150 or fewer workers’ compensation files, including complex claims.
Initiates and investigates promptly.
Determines compensability of claims and administers benefits based upon state law and following established Company guidelines.
Manages medical treatment and medical billing, authorizing as appropriate.
Refers cases to outside defense counsel.
Directs and manages as appropriate.
Communicates with claimants, providers, and vendors regarding claims issues.
Computes and sets reserves within Company guidelines. Limits are more significant than those allowed for Claims Examiner I and Claims Examiner II.
Settles and finalizes all claims and obtains authority as designated.
Maintains diary system for case review and documents file to reflect the status and work 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.
Conducts file reviews independently.
Other duties as assigned.