Workers Compensation Claims Examiner II

Job Details

Job Details Level: Experienced

Job Location:

Honolulu
- Kapolei, HI 96814

Position Type:
Full Time Education Level: High School Diploma or GEDSalary Range: $70,000.00 - $85,000.00 Salary

Travel Percentage :
Negligible

Job Shift: Day Job Category:
Admin
- Clerical This is a Hybrid position with the potential to be remote.

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. Directs and manages as appropriate.
• Communicates with claimants, providers and vendors regarding claims issues.
• Computes and set 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

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 EFFORTa. Reasoning development::

X 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 additional and subtraction; copying figures, counting, and recording.

X 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.

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