Workers' Compensation Claims Examiner III (Hybrid- REMOTE)

TRISTAR RISK MANAGEMENT•Fresno, CA

148d•$84,000 - $84,000•Hybrid

About The Position

Under general 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 in the office, in a timely manner, is inherently required of this position.

Requirements

Bachelor’s degree in related field (preferred); and one (1) to five (5) years 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.
Ability to independently and effectively manage very complex claims.
Proficient in Word and Excel (preferred).
Certification and/or or license as required by State regulation.
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, up to 10 pounds frequently, and a negligible amount of force constantly to move objects. Sedentary work involves sitting most of the time.
Visual requirements: Near vision, Mid-range vision, Depth perception, Color vision.
Physical activity necessary to perform the job: Stooping, Kneeling, Crouching, Reaching, Standing, Walking, Pushing, Pulling, Lifting, Fingering, Grasping.
Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.
Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making fine adjustments on machined parts.
Repetitive Motion: Substantial movements (motions) of the wrists, hands, and/or fingers.

Nice To Haves

Proficient in Word and Excel

Responsibilities

Effectively manages a caseload of 150 to 180 workers’ compensation files, including complex claims.
Initiates and conducts claims investigation in a timely manner.
Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines.
Manages medical treatment and medical billing, authorizing as appropriate.
Refers cases to outside defense counsel as appropriate.
Monitors legal aspects.
Communicates with claimants, providers and vendors regarding claims issues.
Computes and set reserves within Company guidelines.
Settles and/or finalize all claims and obtains authority as designated.
Maintains diary system for case review and document file to reflect the status 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 TRISTAR loss control staff when appropriate.
Adheres to all Company policies and procedures.
Participates in file reviews, as needed.
Other duties as assigned.