Workers' compensation Claims Examiner I
TRISTAR Insurance Group is seeking a Workers' Compensation Claims Examiner I. This entry-level position involves managing all aspects of medical-only claims handling, including client and claimant interactions, claims investigations, and communication with various stakeholders to ensure efficient claims resolution.
Responsibilities
- Effectively manages a caseload of 110 to 150 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. Limits are less than those allowed for Claims Examiner III, but larger than those for Claims Examiner I
- 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
Skills
- 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
Company Overview