Workers Compensation Claims Examiner III

Workers Compensation Claims Examiner III

Hybrid
• Houston Office
- Houston, TX 77040

Salary Range $73,000.00 - $88,000.00 Salary Level Experienced Position Type Full Time Job Shift Day Education Level High School Diploma or GED

Travel Percentage None Category Admin
- Clerical

This position will be a hybrid position if you reside in Houston, TX, but can be a remote position outside of Houston, TX if you do not reside in Houston, TX. Must be willing to attend certain meetings in person.

POSITION SUMMARY:

Under minimal supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients, claimants on the phone, and with management, other Claims Examiners, and other TRISTAR staff in the office; therefore consistently being at work in the office, in a timely manner, is inherently required of this position.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a caseload of 110 to 150 workers' compensation files, including very complex claims.
• Initiates and conducts investigation in a timely manner.
• Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines.
• Manages medical treatment and medical billing, authorizing as appropriate.
• Communicates with claimants, providers and vendors regarding claims issues.
• Computes and set reserves within Company guidelines.
• 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 independently.
• Other duties as assigned.

* Essential job function.

EQUIPMENT OPERATED/USED:
Computer, 10-key, fax machine, copier, printer, and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING:
Appropriate office attire

QUALIFICATIONS

REQUIRED:

Education/Experience :
High School Diploma or GED required. Bachelor's degree in related field (preferred); five (5) or more years related experience; or equivalent combination of education and experience.

Knowledge,

Skills and Abilities

:

• 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).

Other Qualifications :

• Texas Workers Compensation License

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORTa. 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.

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.

Add, subtract, multiply, and divide whole numbers.

X 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 application.

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…