Workers Compensation Claims Examiner III

Tristar Insurance•Rancho Cordova, CA

15d•$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 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. It also includes mentoring less experienced examiners and may involve claims management for other jurisdictions’ workers’ compensation claims. The position is based in Sacramento - Rancho Cordova, California, and is listed as full-time with a day shift. The stated salary range is $90,000 to $95,000 per year. The role uses standard office equipment and requires appropriate office attire. Its physical requirements are classified as light work, with specified visual, physical, communication, and repetitive-motion activities.

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 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.

Nice To Haves

Proficiency in Microsoft Word and Excel (preferred).

Responsibilities

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 for claim handling.
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 regarding 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, work performed, and a plan of action.
Promptly communicate appropriate information to clients to resolve claims efficiently, including injury trends and other 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 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.
Adhere to all TRISTAR company policies and procedures.