Workers Compensation Claims Examiner III

Job Summary

Workers Compensation Claims Examiner III

Teema Group

Full-time

In-Office | Kapolei, HI, United States

At the direction of the Claims Supervisor and/or Claims Manager, the Claims Examiner II / III manages all aspects of workers’ compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines.

This role requires frequent interaction with clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff
.

The level of complexity, litigation exposure, settlement authority, and leadership responsibility will be commensurate with the examiner’s experience and designation (Level II or Level III).

• Manage a full caseload of workers’ compensation claims, including complex indemnity claims
  .
• Initiate, conduct, and document timely and thorough claim investigations.
• Determine compensability and administer benefits in accordance with state laws, rules, and company/client handling instructions
  .
• Manage medical treatment and medical billing; authorize services as appropriate.
• Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.
• Compute and set reserves in accordance with Company and Client guidelines.
• Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.
• Settle and/or finalize claims and obtain appropriate settlement authority.
• Conduct scheduled file reviews and respond to client inquiries.
• Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.
• Adhere to all TRISTAR company policies, procedures, and best practices.
• Utilize office systems and technology efficiently to manage caseload responsibilities.
• Perform other related duties as assigned.

• Manage very complex, catastrophic, and litigated indemnity claims from inception to conclusion.
• Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.
• Identify and manage:
  • Subrogation opportunities
  • Apportionment potential
  • Excess reporting criteria and reimbursement
• Prepare and assist with state audits, regulatory reporting, and client-specific reporting requirements
  .
• Develop and execute proactive claim strategies to drive timely and cost-effective resolution.
• Conduct detailed client file reviews and participate in client meetings as needed.
• Mentor and provide technical guidance to less experienced Claims Examiners.
• Handle multi-jurisdictional workers’ compensation claims as assigned.

Essential job functions.

• Claims Examiner II:
  • Bachelor’s degree in a related field (preferred)
  • Minimum 3+ years of workers’ compensation claims experience, or equivalent combination of education and experience
• Claims Examiner III:
  • Minimum 5+ years of progressive workers’ compensation claims experience
  • Demonstrated experience handling complex and litigated indemnity claims