Workers' compensation Claims Examiner III

Tristar Insurance•Philadelphia, PA

2d•$85,000 - $95,000•Hybrid

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

Requirements

Three (3) or more 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.
Must be licensed to handle claims in NY
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: Stooping, Kneeling, Crouching, Reaching, Standing, Walking, Pushing, Pulling, Lifting, Fingering, Grasping, Talking, Hearing, Feeling, Repetitive Motion.
Working conditions: Significant work pace/pressure.

Nice To Haves

Bachelor’s degree in related field
Experience handling NJ claims a plus
Proficient in Word and Excel
Mathematical development: Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
Language development: Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

Responsibilities

Manages a caseload of 125 to 150 workers’ compensation files, including very complex claims. Jurisdiction is NY.
Initiates and conducts 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.
Directs and manages as appropriate.
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 documents 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.
Conducts file reviews independently.
Other duties as assigned.