Workers Compensation Claims Examiner I

POSITION SUMMARY: Under close supervision, manages all aspects of medical only and 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.

DUTIES AND RESPONSIBILITIES:

• Effectively manages an assigned medical-only caseload of workers’ compensation claims.
• Initiates and conducts 3-point contacts promptly according to Client and TRISTAR.
• 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 Indemnity Examiner if claims meet indemnity conversion qualification per TRISTAR best practices.
• Communicates with claimants, providers, and vendors regarding claims issues.
• Computes and sets reserves within Company guidelines. Limits are $10,000, and the claim is referred to the Indemnity Examiner once met.
• Maintains diary system for case review and document file to reflect the status of 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.
• Adheres to all Company policies and procedures.
• Other duties as assigned.

*Essential job function.

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

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire

Qualifications

QUALIFICATIONS REQUIRED:

Education/Experience: High School Diploma or GED required;

Bachelor’s degree in a related field (preferred); one (1) year or more related experience; or an equivalent combination of education and experience.

Licenses:

Must have an active IN, MN, or MI adjuster’s license or license in state with reciprocity.

Knowledge, Skills, and Abilities:

• Technical understanding of statutory regulations and medical terminology.E
• 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.
• Proficient in Word and Excel (preferred).

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

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORT a. Reasoning development:: Follow one- or two-step instructions; routine, repetitive tasks. 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; various 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. X arithmetic calculations involving fractions, decimals, and percentages.