Workers Compensation Claims Examiner II

Honolulu - Kapolei, HI 96814 Overview Salary Range: $70,000.00 - $85,000.00 Salary,
Position Type: Full Time,
Job Shift: Day,
Education Level: High School Diploma or GED,
Travel Percentage: Negligible,
Category: Admin - Clerical – Workers Compensation Claims Examiner III

At the Direction of the Claims Supervisor, manages all aspects of indemnity and future medical claims from inception to conclusion within established authority and guidelines. This position requires considerable interaction with clients, claimants, medical providers, vendors, and other TRISTAR staff in the office.

• Effectively manages a caseload of 130 to 150 workers’ compensation files, including complex claims.
• Initiates and conducts investigation in a timely manner.
• Determines compensability of claims and administer benefits, based upon state laws/Rules and in accordance with established Company guidelines.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Refers cases to outside defense counsel and directs and manages as appropriate.
• Communicates with claimants, providers and vendors regarding claims issues.
• Computes and sets reserves within Company/Client 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.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns.
• Adheres to all Company policies and procedures.
• Conducts file reviews.
• Adheres to agreed client handling instructions.
• Other duties as assigned.
• Essential job function.

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

Appropriate office attire.

• Education/
  
  Experience:
  
  Bachelor’s degree in related field (preferred); three (3) or more 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).
• Certifications and/or licenses as required by state regulation.

• Medical, Dental, Vision, Disability and Life Insurance
• 401(k) plan
• Paid time off
• Paid holidays

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 addition and subtraction; 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 calculus, factor analysis, and probability determination.

c. Language development: Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing. Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail;

write form letters or routine correspondence; interpret written work instructions; interview job applicants. Ability…