Claims Examiner III (Hybrid)

Hybrid Sacramento - Rancho Cordova, CA 95670

Salary Range $90,000.00 - $95,000.00 Salary Level Experienced Position Type Full Time Job Shift Day Category Insurance

Claims Examiner III (Hybrid)

Please make sure to complete all the questions and navigate to the end of the application to sign it. This position is a hybrid, temp-to-hire opportunity, and SIP is required for this position.

Position Summary: At the direction of the claims supervisor and/or manager, manages all aspects of complex and litigated indemnity claims from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants, medical providers, attorneys, vendors, nurse and vocational case managers and other TRISTAR staff.

Duties and Responsibilities:

• Effectively manages a caseload of indemnity claim files, including very complex and litigated claims.
• Initiates and conducts investigation in a timely manner.
• Determines compensability of claims and administers benefits based upon state law and TRISTAR best practices for claim handling.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refers cases to outside defense counsel and participates in litigated matters.
• Communicates with claimants, attorneys, providers and vendors regarding claims issues.
• Works in an organized and proactive manner.
• Computes and sets reserves within company guidelines.
• Settles and/or finalizes 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, including a plan of action.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns.
• Conducts file reviews as scheduled by the client and management.
• Identifies and reviews claims for apportionment assignment.
• Identifies and investigates subrogation potential and pursues recovery.
• Identifies claim standard criteria for excess reporting and reimbursement.
• Assists with state audit and reporting responses.
• Mentors less experienced examiners.
• Other duties as assigned and including claims management of other jurisdictional workers' comp claims.
• Adheres to all TRISTAR company policies and procedures.

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

Qualifications Required:

Education/Experience: Minimum five (5) or more 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:

Licenses as required by jurisdiction.

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 checklist of mental and physical requirements