Claims Examiner III

Sacramento - Rancho Cordova, CA 95670

Salary Range: $85,000.00 - $95,000.00 Salary

Position Type:
Full Time

Job Shift:
Day

Education Level:
High School Diploma or GED

Travel Percentage :
None

Category:
Insurance Claims Examiner III

Please sign the application at the end. SIP required

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 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 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 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

Minimum five (5) or more years related experience; or equivalent combination of education and experience. HS diploma required, BS preferred

• 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).

Licenses as required by Jurisdiction.. SIP required

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

[see separate attachment for a copy of checklist of mental and physical requirements]

MENTAL EFFORT
a. Reasoning development:
Follow one- or two-step instructions; routine, repetitive task.
Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.
Follow written, verbal, or diagrammatic instructions; several concrete variables.
X Solve practical problems; 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 additional and subtraction; copying figures, counting, and recording.
Add, subtract, multiply, and divide whole numbers.
X Arithmetic calculations involving fractions, decimals, and percentages.
Arithmetic, algebraic, and geometric calculations.
Advanced mathematical and statistical…