Workers Compensation Claims Examiner III

Overview

Location:

Honolulu - Kapolei, HI 96814

Salary Range: $85,000.00 - $95,000.00

Position Type:
Full Time

Job Shift:
Day

Education Level:
High School Diploma or GED

Travel Percentage :
None

Category:
Admin - Clerical

Title:

Workers Compensation Claims Examiner III

At the direction of the Claims Supervisor and/or Manager, manages all aspects of complex and litigated indemnity claims from inception to conclusion within established authority and guidelines. Requires substantial interaction with clients, claimants, medical providers, attorneys, vendors, nurse and vocational case managers, and other TRISTAR staff.

• Effectively manage a caseload of indemnity claim files, including very complex and litigated claims.
• Initiate and conduct investigations in a timely manner.
• Determine compensability of claims and administer benefits based upon state law and TRISTAR best practices for claim handling.
• Manage medical treatment and medical billing, authorizing as appropriate.
• Refer cases to outside defense counsel and participate in litigated matters.
• Communicate with claimants, attorneys, providers and vendors regarding claims issues.
• Work in an organized and proactive manner.
• Compute and set reserves within company guidelines.
• Settle and/or finalize all claims and obtain authority as designated.
• Maintain diary system for case review and document file to reflect status and work performed, including a plan of action.
• Communicate appropriate information promptly to the client to resolve claims efficiently, including injury trends or other safety related concerns.
• Conduct file reviews as scheduled by the client and management.
• Identify and review claims for apportionment assignment.
• Identify and investigate subrogation potential and pursue recovery.
• Identify claim standard criteria for excess reporting and reimbursement.
• Assist with state audit and reporting responses.
• Mentor less experienced examiners.
• Handle other duties as assigned, including claims management of other jurisdictional workers’ comp claims.
• Adhere to all TRISTAR company policies and procedures.

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

Appropriate office attire.

• Minimum five (5) 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).
• Licenses as required by jurisdiction.

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