Job Details

Workers' Compensation Claims Examiner III (Hybrid- REMOTE)

Position Summary:

Under general 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 150 to 180 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.

Equipment Operated/Used:

Computer, 10-key, fax machine, copier, printer and other office equipment.

Special Equipment or Clothing:

Appropriate office attire.

Qualifications:

Qualifications Required:

Education/Experience: Bachelor's degree in related field (preferred); and one (1) to five (5) years 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 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).

Other Qualifications:

• Certification and/or or license as required by State regulation.

Mental and Physical Requirements:

1. Mental Effort:

• 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.
• 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 intellectual and practical problems; comprehend most obscure concepts.
• Mathematical development:
• Simple additional and subtraction; copying figures, counting, and recording.
• Add, subtract, multiply, and divide whole numbers.
• Arithmetic calculations involving fractions, decimals, and percentages.
• Arithmetic, algebraic, and geometric calculations.
• Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.
• Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.
• Language development:
• Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.
• Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.
• Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.
• Ability to compose original correspondence, follow technical manuals, and have increased contact with people.
• 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.

2. Physical Effort:

• Physical activity required to perform the job:
• Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.
• Light work:
• Exerting up to 20 pounds of force occasionally
• Exerting up to 10 pounds frequently
• Exerting a negligible amount of force constantly to move objects
• Medium work:
• Exerting up to 50 pounds of force occasionally
• Exerting up to 20 pounds of force frequently
• Exerting up to 10 pounds of force constantly to move objects
• Heavy work:
• Exerting up to 100 pounds of force occasionally
• Exerting up to 50 pounds of force frequently
• Exerting up to 20 pounds of force constantly to move objects
• Very heavy work:
• Exerting in excess of 100 pounds of force occasionally
• Exerting in excess of 50 pounds of force constantly to move objects
• Exerting in excess of 20 pounds of force constantly to move objects
• Visual requirements necessary to perform the job:
• Far vision: clarity of vision at 20 feet or more
• Near vision: clarity of vision at 20 inches or less
• Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet
• Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are
• Color vision: ability to identify and distinguish colors
• Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point
• Physical activity necessary to perform the job and frequency:
• Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.
• Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
• Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.
• Kneeling: Bending legs at knee to come to a rest on knee or knees.
• Crouching: Bending the body downward and forward by bending legs and spine.
• Crawling: Moving about on hands and knees or hands and feet.
• Reaching: Extending hand(s) and arm(s) in any direction.
• Standing: Particularly for sustained periods of time.
• Walking: Moving about on foot to accomplish tasks