Claims Examiner III; Hybrid

Fresno Office - Fresno, CA 93727 Overview Salary Range: $83,000.00 - $83,000.00 Salary 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. SIP is a must.

Under general supervision, manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants on the phone, and with management, other Claims Examiners, and other TRISTAR staff in the office; therefore consistently being at work in the office, in a timely manner, is inherently required of this position.

• Effectively manages a caseload of 150 to 180 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.

* Essential job function.

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

Appropriate office attire.

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 license as required by State regulation.

1. 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 addition 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 techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

c. Language development:

Ability to understand and follow verbal or demonstrated instructions; write…