Workers Compensation Claims Examiner III

Overview

Milwaukee - Waukesha, WI 53186

Salary Range: $70,000.00 - $85,000.00 Salary/year

Position Type:
Full Time

Job Shift:
Day

Education Level:
High School Diploma or GED

Travel Percentage :
None

Category:
Admin - Clerical

Workers Compensation Claims Examiner III

This is a remote position.

A Workers compensation Adjuster's license for MN & MI is preferred but will also consider an adjuster's license for TX, FL & Indiana.

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 on time is inherently required of this position.

• Effectively manages a caseload of 150 or fewer workers’ compensation files, including complex claims.
• Initiates and investigates promptly.
• Determines compensability of claims and administers benefits based upon state law and following 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 sets reserves within Company guidelines. Limits are more significant than those allowed for Claims Examiner I and Claims Examiner II.
• Settles and finalizes all claims and obtains authority as designated.
• Maintains diary system for case review and documents file to reflect the status and work performed on the file.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns.
• Involves TRISTAR loss control staff when appropriate.
• Adheres to all Company policies and procedures.
• Conducts file reviews independently.
• Other duties as assigned.

* Essential job function.

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

Appropriate office attire

Education/

Experience:

Bachelor’s degree in a related field (preferred); three (3) or more years of related experience; or equivalent combination of education and experience.

Licenses: WC Adjuster’s license for MI & MN preferred but will also consider an adjuster's license for TX, FL & Indiana.

Knowledge, Skills, and Abilities:

• Technical knowledge of statutory regulations and medical terminology.
• Analytical skills.
• Excellent written and verbal communication skills, including conveying 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).

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

1. MENTAL EFFORT

a. Reasoning development:
Follow one- or two-step instructions; routine, repetitive task. Carry out detailed 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. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires…