Workers' Claims Examiner I​/Medical

Job Details:
Level: Experienced,

Job Location:

Dallas
- Irving, TX 75038, Position Type:
Full Time, Education Level: High School Diploma or GED, Salary Range: $24.03 - $26.44 Hourly,

Travel Percentage :
None,

Job Shift: Day, Job Category:
Admin
- Clerical,

POSITION SUMMARY:

Under close to moderate supervision, manages workers’ compensation medical-only claims from inception through resolution, with total claim exposure not exceeding $10,000 and within assigned authority limits and established company and client guidelines.

• Manages medical-only workers’ compensation claims with total exposure up to $10,000, within assigned authority limits and under close to moderate supervision.*
• Initiates and conducts timely investigations to gather information needed to evaluate claims. *
• Determines compensability of medical-only claims in accordance with applicable state laws and company guidelines, seeking supervisory guidance on disputed or unusual matters. *
• Coordinates and monitors medical treatment and medical billing, providing authorization within assigned authority. *
• Communicates professionally with claimants, employers, medical providers, and vendors regarding claim status, treatment, billing, and other claims issues. *
• Calculates, establishes, and adjusts reserves within assigned authority and company guidelines.
• Monitors claims for lost time, potential indemnity benefits, increased medical exposure, litigation, or other developments requiring supervisory review or reassignment. *
• Promptly refers claims exceeding $10,000 in total exposure or the medical-only scope to the supervisor for review and appropriate reassignment. *
• Maintains a diary system for timely case review and documents claim files to accurately reflect claim status and handling activities. *
• Promptly communicates relevant information to clients, including injury trends and safety concerns. *
• Adheres to all company policies, procedures, and applicable client claims handling instructions. *
• Participate in file reviews as needed.
• Performs other duties as assigned.

* Essential job function.

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

Appropriate office attire.

QUALIFICATIONS

REQUIRED:

Education/

Experience:

Bachelor’s degree in related field (preferred); and one (1) to three (3) years related experience; or equivalent combination of education and experience.

• Working knowledge of applicable workers’ compensation laws, statutory requirements, and medical terminology relevant to medical-only claims.
• Ability to investigate and manage medical-only claims within assigned authority and established guidelines.
• Analytical skills to evaluate claim information, medical documentation, and billing.
• Ability to recognize changes in claim exposure or complexity and seek supervisory guidance promptly.
• Strong organizational skills and the ability to maintain a diary system, prioritize tasks, and meet deadlines.
• Effective written and verbal communication skills, including the ability to explain claims information clearly to claimants, clients, and staff.
• Ability to interact professionally with individuals at all levels of the business environment.
• Proficiency in Microsoft Word and Excel preferred.

• Certification and/or or license as required by State regulation.

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

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORT

a. Reasoning development:

Follow one- or two-step instructions; routine, repetitive task.

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

Solve practical…