Worker's Compensation Claims Examiner III

Please make sure to complete all the questions in the application and continue through to the end in order to sign and submit it.

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, management, other Claims Examiners, and other TRISTAR staff.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a caseload of 150 workers’ compensation files, including very complex claims.*
• Initiates and conducts investigations in a timely manner.*
• Determines compensability of claims and administers benefits, based upon state law 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 sets reserves within Company guidelines. Limits are larger than those allowed for Claims Examiner I and Claims Examiner II.*
• 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.*
• 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.

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

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire

Qualifications

QUALIFICATIONS REQUIRED:

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.

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.

Here are some of the benefits you can enjoy in this role:

• Medical, Dental, Vision Insurance.
• Life and Disability Insurance.
• 401(k) Plan
• Paid Holidays
• Paid Time Off.
• Referral bonus.

Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]

	MENTAL AND PHYSICAL REQUIREMENTS
	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. 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 record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants. X Ability to compose original correspondence, follow technical manuals, and have increased contact with people. Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.
	2. PHYSICAL EFFORT a. Physical activity required to perform the job: Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. X Light work: a. Exerting up to 20 pounds of force occasionally b. &