Claims Examiner III (Hybrid)

TRISTAR Insurance Group is seeking a Claims Examiner III to manage all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. This role involves considerable interaction with clients and requires effective management of a caseload of workers’ compensation files, conducting claims investigations, and communicating with various stakeholders.

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

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
• Certification and/or license as required by State regulation. SIP
• Proficient in Word and Excel (preferred)

Benefits

• Medical, Dental, Vision Insurance.
• Life and Disability Insurance.
• 401(k) Plan
• Paid Holidays
• Paid Time Off.
• Referral bonus.

Company Overview