Workers' Compensation Claims Examiner III

**Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it. Please note that this position is a hybrid, temp-to-hire opportunity.** **POSITION SUMMARY**: 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, with management, other Claims Examiners, external business partners, and other TRISTAR staff. **DUTIES AND RESPONSIBILITIES:** • Effectively manages an average caseload of 130 workers’ compensation files, including very complex claims.\* • Initiates and conducts an investigation in a timely manner.\* • Determines compensability of claims and administers benefits, based upon state law and in accordance with established Company guidelines.\* • Develops and manages claims through well-developed action plans; continues to work the action plan to stay on task and to bring the claim to an appropriate and timely resolution. • Manages medical treatment and medical billing, authorizing as appropriate.\* • Calculates and pays benefits due and approves all claim payments. • Refers cases to outside defense counsel. Directs and manages as appropriate.\* • Manages claim recoveries of all types, including deductible and subrogation. • Communicates with clients, claimants, providers, and vendors regarding claims issues.\* • Computes and sets reserves within Company guidelines.\* • Settles and/or finalizes all claims and obtains authority as designated.\* • Maintains a diary system for case review and documents the 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.\* • Adheres to all Company policies and procedures.\* • Conducts file reviews independently.\* • Other duties as assigned. \* Essential job function. **EQUIPMENT OPERATED/USED:** Computer, 10-key, fax machine, copier, printer, and other office equipment. **SPECIAL EQUIPMENT OR CLOTHING:** Appropriate office attire **QUALIFICATIONS REQUIRED:** **Education/Experience:** Bachelor’s degree in related field (preferred); five (5) or more years of related experience; or equivalent combination of education and experience. **Knowledge, Skills, and Abilities:** • 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 persons at all levels in the business environment. • Ability to independently and effectively manage very complex claims. • Proficient in Word and Excel (preferred). • Knowledge of self-insured claims handling (preferred). • City, County and/or District claims handling experience (preferred). **Other Qualifications:** • Certifications and/or licenses as required by State regulation. **Here are some of the benefits you can enjoy in this role:** - Medical, Dental, Vision Insurance. - Life and Disability Insurance. - 401(k) Plan - Paid Holidays - Paid Time Off. - Referral bonus. **Mental and Physical Requirements****:** [see separate attachment for a copy of the checklist of mental and physical requirements] | | **MENTAL AND PHYSICAL REQUIREMENTS** | | --- | --- | | | **1. MENTAL EFFORT** a. Reasoning development: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intell…