Claims Examiner III WC CON 10.29.18
TRISTAR
Concord, Concord, CA
7h ago

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, 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.

    DUTIES AND RESPONSIBILITIES :

  • Effectively manages a caseload of 100 to 125 indemnity files, including very complex claims.*
  • 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. Limits are larger than those allowed for Claims Examiner I and Claims Examiner II.*
  • 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.
  • Essential job function.
  • Qualifications

    Education / Experience : Bachelor’s degree in related field (preferred); three (3) or more years related experience; or equivalent combination of education and experience.

    High School Diploma or GED required.

    Knowledge, Skills and Abilities :

  • 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.
  • Effective multi tasker
  • Must be able topresent claim reviews to client with confidence
  • High level customer service
  • Proficient in Word and Excel (preferred).
  • SIP certified
  • Other Qualifications :

  • Certifications and / or licenses as required by State regulation.
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