Workers Compensation Claims Examiner III _ NY claims

Tristar Insurance•Philadelphia, PA

6d•$85,000 - $95,000•Hybrid

About The Position

Under minimal supervision, manages all aspects of indemnity workers’ compensation claims from inception through conclusion, within established authority and guidelines. The role handles New York claims, including very complex cases, and requires significant interaction with clients, claimants by phone, management, other Claims Examiners, and TRISTAR staff. The position is hybrid; candidates in the surrounding Philadelphia area are preferred, while candidates outside that area may work remotely. Consistent, timely attendance in the office is described as inherently required for the position. The role manages a caseload of approximately 115 to 125 files and conducts independent file reviews. It requires New York claims-handling licensure and technical knowledge of statutory regulations and medical terminology.

Requirements

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.

Nice To Haves

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

Responsibilities

Manage a caseload of 115 to 125 workers’ compensation files, including very complex claims.
Initiate and conduct claim investigations in a timely manner.
Determine claim compensability and administer benefits according to state law and company guidelines.
Manage medical treatment and medical billing, authorizing treatment or billing as appropriate.
Refer cases to outside defense counsel and direct and manage cases as appropriate.
Communicate with claimants, providers, and vendors regarding claims issues.
Compute and set reserves within company guidelines; the position has higher limits than Claims Examiner I and II.
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.