Claims Examiner III; Hybrid

Overview

Sacramento - Rancho Cordova, CA 95670

Salary Range: $90,000.00 - $95,000.00 Salary/year

Position Type:
Full Time

Job Shift:
Day

Category:
Insurance

Claims Examiner III (Hybrid)

Please make sure that you complete all the questions and navigate to the end of the application to sign the application.

This position is a hybrid and a temp-to-hire opportunity.

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.

• 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.*
• Work 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 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.*
• Identify and review claims for the 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.

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

Appropriate office attire

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 the 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 the 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 the checklist of mental and physical requirements]

1. MENTAL EFFORT

a. Reasoning development:

Follow one- or two-step instructions, routine, repetitive tasks.

Carry out detailed but uninvolved written or verbal instructions, and deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions and several concrete variables.

X Solve practical problems; a 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.

b. Mathematical development:

Simple addition and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole…