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Workers Compensation Claims Examiner I

Remote: 
Full Remote
Contract: 
Full time
Salary: 
19 - 192K yearly
Experience: 
Junior (1-2 years)
Work from: 
Canada, United States

Offer summary

Qualifications:

High school diploma or GED required, Bachelor's degree in related field preferred, 1 year related experience or equivalent.

Key responsabilities:

  • Manage indemnity claims with supervision
  • Conduct investigations and determine compensability
  • Communicate with claimants and vendors
  • Maintain a diary system for case review
  • Adhere to company policies and procedures
TRISTAR Insurance Group logo
TRISTAR Insurance Group Insurance SME https://www.tristargroup.net/
501 - 1000 Employees
About TRISTAR Insurance Group
TRISTAR began as an insurance program manager and medical malpractice claims administrator in 1987. Workers compensation claims management services were added in our offerings in 1989, and the Company was renamed TRISTAR Risk Management in 1995. As managed care and benefits administration services were added to our offerings, the organization grew into TRISTAR. We are the largest privately held third party claims administrator in United States. We empower more than 1,000+ professionals in offices throughout the United States, focusing business operations in three divisions: property casualty claims management, benefits administration, and managed care services. We are true to our values of RESPECT, INTEGRITY, TRUST, and EXCELLENCE, making the right choices both financially and ethically. At TRISTAR we strive to create an environment of respect, wherein all of us are encouraged to learn and to grow, to provide exceptional service to our clients and in turn to enjoy the satisfaction that comes from a job well done. We believe that to provide real service, we must contribute something which cannot be bought or measured with money: sincerity and integrity. At TRISTAR, you help create a world in which together we "transform risk into opportunity".
See more TRISTAR Insurance Group offers

Job description

Job Details
Level:    Entry
Job Location:    Signal Hill Office - Signal Hill, CA
Position Type:    Full Time
Education Level:    High School Diploma or GED
Salary Range:    $24.00 - $30.00 Hourly
Travel Percentage:    None
Job Shift:    Day
Job Category:    Insurance
Workers Compensation Claims Examiner I

Please complete all of the questions, information and sign your application at the end.

OSITION SUMMARY:  Under close 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 indemnity workers’ compensation files with supervison.*
  • Initiates and conducts investigation in a timely manner based upon state law and TRISTAR Best Practices for claim handling with direction from supervisor.*
  • Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines with direction from supervisor.*
  • Manages medical treatment and medical billing, authorizing as appropriate based on TRISTAR claims Policies and Procedures
  • Staffs complex claims with supervisor to establish plan of action and obtain settlement authority to commence settlement negotiations with Applicant Attorney.
  • Communicates with claimants, providers and vendors regarding claims issues.
  • Maintains diary system for case review and document file to reflect the status and work being performed on the file.
  • Computes and set reserves based upon TRISTAR best practices with direction from supervisor.
  • Negotiates and/or finalize all claims based on settlement authority obtained from client with direction from supervisor.
  • 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 with direction from supervisor.
  • Adheres to all TRISTAR company policies and procedures.
  • Conducts ongoing file reviews with supervisor for development.
  • Other duties as assigned by supervisor.

 

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:  High school diploma or GED required; Bachelor’s degree in related field (preferred); (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 people at all levels in the business environment.
  • Ability to effectively manage claims with high level of supervision.
  • Proficient in Word and Excel (preferred).

 

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

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

 

  1.   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.
  1.   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.
  1.        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.
  1.   PHYSICAL EFFORT

 

  1.        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:

  1.     Exerting up to 20 pounds of force occasionally
  2.     Exerting up to 10 pounds frequently
  3.     Exerting a negligible amount of force constantly to move objects

 

          (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

 

          Medium work:

  1.     Exerting up to 50 pounds of force occasionally
  2.     Exerting up to 20 pounds of force frequently
  3.     Exerting up to 10 pounds of force constantly to move objects

 

          Heavy work:

  1.     Exerting up to 100 pounds of force occasionally
  2.     Exerting up to 50 pounds of force frequently
  3.     Exerting up to 20 pounds of force constantly to move objects

 

          Very heavy work:

  1.     Exerting in excess of 100 pounds of force occasionally
  2.     Exerting in excess of 50 pounds of force constantly to move objects
  3.     Exerting in excess of 20 pounds of force constantly to move objects

 

    

  1. Visual requirements necessary to perform the job:

 

          Far vision:  clarity of vision at 20 feet or more

 

 X      Near vision:  clarity of vision at 20 inches or less

 

 X      Mid-range vision:  clarity of vision at distances of more than 20 inches and less than 20 feet

 

          Depth perception:  the ability to judge distance and space relationships, so as to see objects where and as they actually are

 

          Color vision:  ability to identify and distinguish colors

 

          Field of vision:  ability to observe an area up or down or to the right or left while eyes are fixed on a given point

 

 

  1.   PHYSICAL EFFORT (cont.)

    FREQUENCY
  1.         Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):

 

       Climbing:      Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms.  Body agility is emphasized.  This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.

 

       Balancing:     Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces.  This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

 

       Stooping:       Bending body downward and forward by bending spine at the waist.  This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.

 

       Kneeling:       Bending legs at knee to come to a rest on knee or knees.

 

       Crouching:    Bending the body downward and forward by bending legs and spine.

 

       Crawling:      Moving about on hands and knees or hands and feet.

 

       Reaching:      Extending hand(s) and arm(s) in any direction.

 

       Standing:       Particularly for sustained periods of time.

 

       Walking:       Moving about on foot to accomplish tasks, particularly for long distances.

 

       Pushing:        Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.

 

       Pulling:         Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.

 

       Foot

       Motion:          Using feet to push pedals.

 

       Lifting:          Raising objects from a lower to a higher position or moving objects horizontally from position to position.  This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.

 

 X    Fingering:     Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.

 

 X    Grasping:      Applying pressure to an object with the fingers and palm.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Frequently

 

 

Occasionally

 

 

 

 

Bottom of Form

 

 

 

Required profile

Experience

Level of experience: Junior (1-2 years)
Industry :
Insurance
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Hard Skills

Medical TerminologyClaims ProcessingSpeech FluencyRegulatory Compliance

Other Skills

  • Verbal Communication Skills
  • Analytical Skills
  • Social Skills
  • Time Management
Are you interested?

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