Workers Compensation Claims Examiner III _ NY claims

TRISTAR RISK ENTERPRISE MANAGEMENT•Philadelphia, PA

21d•$85,000 - $95,000•Hybrid

About The Position

Under minimal supervision, the Workers Compensation Claims Examiner III manages all aspects of indemnity claims handling from inception through conclusion, within established authority and guidelines. The position handles New York workers’ compensation claims and manages a caseload of approximately 115 to 125 files, including very complex claims. It involves considerable telephone interaction with clients and claimants, as well as communication with management, other Claims Examiners, and TRISTAR staff. Consistent, timely attendance in the office is described as inherently required, although the role is hybrid; candidates outside the surrounding Philadelphia area may work remotely. The position is based at the Philadelphia office, and travel is not required. The examiner investigates claims, determines compensability, administers benefits under state law and Company guidelines, manages medical treatment and billing, establishes reserves, and settles or finalizes claims within designated authority. The role also includes maintaining claim documentation and diary systems, coordinating with defense counsel and other parties, conducting independent file reviews, and communicating relevant claim information and safety concerns to clients. The role requires a high school diploma or GED and at least three years of related experience, or an equivalent combination of education and experience. A bachelor’s degree in a related field and proficiency in Word and Excel are preferred. The candidate must be licensed to handle claims in New York and have technical knowledge of statutory regulations and medical terminology, analytical ability, strong written and verbal communication skills, and the ability to independently manage very complex claims.

Requirements

High school diploma or GED.
Three or more years of related experience, or an equivalent combination of education and experience.
Must be licensed to handle claims in New York.
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.
Ability to work within established authority and guidelines.

Nice To Haves

Bachelor’s degree in a related field.
Proficiency in Microsoft Word and Excel.
Residence in the surrounding Philadelphia area.

Responsibilities

Manage a caseload of 115 to 125 New York workers’ compensation files, including very complex claims.
Initiate and conduct investigations in a timely manner.
Determine claim compensability and administer benefits in accordance with state law and Company guidelines.
Manage medical treatment and medical billing, authorizing as appropriate.
Refer cases to outside defense counsel and direct and manage those cases as appropriate.
Communicate with claimants, providers, and vendors regarding claims issues.
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 and work performed.
Promptly communicate appropriate information to clients to resolve claims efficiently, including injury trends and safety-related concerns.
Involve TRISTAR loss control staff when appropriate.
Adhere to Company policies and procedures.
Conduct file reviews independently.
Perform other duties as assigned.