Worker Compensation Claims Examiner III (Hybrid)
Summary
Reviews and manages complex workers' compensation claims, determining benefits and coordinating with medical providers and legal teams to resolve cases.
Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it. Please note that this position is a hybrid. SIP is a must.
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 investigations 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 a diary system for case review and documents the 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.*
- Identify and investigate subrogation potential and pursue recovery.*
- Identify claim standard criteria for excess reporting and reimbursement.*
- Assist 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