Claims Examiner III; Hybrid

Job Details

Level: Experienced

Job Location:

Fresno Office - Fresno, CA 93727
Position Type:
Temporary
Salary Range: $35.00 - $43.00 Hourly

Job Shift: Day
Job Category:
Insurance

Under general supervision, manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. SIP is required for this position. This role requires considerable interaction with clients and claimants on the phone, with management, other Claims Examiners, and other TRISTAR staff in the office; consistently being at work in the office, in a timely manner, is inherently required.

• 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 administers 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 and monitors legal aspects.
• Communicates with claimants, providers and vendors regarding claims issues.
• Computes and sets 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 finalizes 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.

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.

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

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. 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 additions and subtractions; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as…