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