Workers Compensation Claims Examiner I

POSITION SUMMARY: Under close supervision manages all aspects of Medical Only 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 or home office location as applicable, in a timely manner, is inherently required of this position.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a caseload of 150 to 200 Medical Only workers’ compensation files.*
• Determines compensability of claims
• Manages medical treatment and medical billing,
• Communicates with claimants, providers and vendors regarding claims issues.*
• Maintains diary system for case review and document file to reflect the status of and work being performed on the file.*
• Communicates appropriate information promptly to the client to resolve claims efficiently,
• Adheres to all Company policies and procedures.*
• Participates in file reviews, as needed.
• Other duties as assigned to include assisting as a claims assistant.

*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: Bachelor’s degree in related field (preferred); and one (1) year 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.
• Proficient in Word and Excel (preferred).

Other Qualifications:

• Certification and/or or license in OR and WA or ability to become certified.

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:: X 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: