Claims Examiner Iii

4 days ago

Concord, United States Tristar Insurance Full time

**JOB SUMMARY: This position can be hybrid**
Investigates, evaluates, disposes and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation and determination of coverage, compensability and responsibility and the setting of proper reserves.

**DUTIES AND RESPONSIBILITIES**:

- Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies, procedures and “Best Practices” and in accordance with any statutory, regulatory and ethics requirements.
- Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority.
- Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers’ Compensation process, requirements and entitlements.
- Interacts with disability and leave examiners’ for coordination of non occupational benefits.
- Prepares and issues notices in accordance with mandated requirements and regularly reviews and stays abreast of applicable laws, rules and regulations that may impact how claims are processed.
- Establishes and maintains proper reserving throughout the life of the claim.
- Identify subrogation potential and pursue the process for reimbursement.
- Complies with carrier excess reporting and threshold requirements.
- Coordinates medical treatment for injured workers and provides information to treating physician(s) regarding the employee’s medical history, health issues and job requirements.
- Fully understands Medicare reporting requirements as they relate to a Workers’ Compensation claim.
- Facilitates early RTW through temporary, transitional, alternate, or modified work.
- Manages all medical aspects of a claim file with a focus on RTW and end of treatment.
- Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority.
- Monitors status and quality of work performed.
- Serves as a liaison between medical providers, employees, legal professionals, clients and vendors.
- Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy.
- Enters and maintains accurate information in the claims management computer system.
- Clearly communicates concise action plans and present plans for moving the claim to resolution.
- Meets with clients to discuss on-going claims or review open claim inventory.
- Effectively controls expenses on all Workers’ Compensation claims.
- Mentors first level WC Examiners.
- All other duties as assigned.

**EQUIPMENT OPERATED/USED**:Computer, fax machine, copier, printer and other office equipment.

**SPECIAL EQUIPMENT OR CLOTHING**:Appropriate office attire.
**QUALIFICATIONS REQUIRED**:
Education: High School Diploma or GED required: Bachelor’s degree in related field (strongly preferred) or equivalent combination of education and experience.

Experience: Three (3) to five (5) years of Workers’ Compensation Claims administration experience required working with self-insured and/or insured claims.
**Preferred Skills**:

- Demonstrated experience working with complex, high exposure and litigated WC claims.
- Appropriately licensed and/or certified in all States in which claims are being handled. Multi-Jurisdiction experience is a (+).
- Bilingual Spanish is a (+)
- Able to work in a fast paced, high stress, changing environment.
- Strong analytical, critical thinking and problem solving skills required.
- Effective verbal and written communication skills required.
- Excellent planning, organizing and negotiation skills required.
- Attention to detail.
- Negotiation and interpretive skills necessary.
- Demonstrated knowledge of established claims strategy and mitigation techniques.
- Establishes and maintains effective working relationships with those contacted in the course of work.
- Good interpersonal skills with an ability to work within a team environment.
- Able to effectively handle multiple priorities simultaneously.
- Works independently.
- **Possesses CA SIP License**

Location: 2325 Clayton Road, Concord, CA 94520

Pay: $90,000.00 - $95,000.00 per year

**Benefits**:

- 401(k)
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Referral program
- Vision insurance

Work setting:

- Hybrid work

Work Location: Hybrid remote

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