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Claims Examiner III - Remote/hybrid/In office

Remote: 
Full Remote
Contract: 
Full time
Salary: 
19 - 192K yearly
Experience: 
Senior (5-10 years)
Work from: 
Canada, California (USA), United States

Offer summary

Qualifications:

High School Diploma or GED required, Bachelor’s degree preferred, Five years of related experience, Familiarity with 4850 is necessary, Certification as required by State regulation.

Key responsabilities:

  • Manage 150 to 180 workers’ compensation claims
  • Conduct timely claims investigations
  • Administer benefits and determine compensability
  • Manage medical treatments and billing authorizations
  • Communicate with clients, claimants, and providers regarding issues
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:    Experienced
Job Location:    Fresno Office - Fresno, CA
Position Type:    Full Time
Education Level:    High School Diploma or GED
Salary Range:    $80,000.00 - $85,000.00 Salary/year
Travel Percentage:    None
Job Shift:    Day
Job Category:    Insurance
Claims Examiner III - Remote/hybrid/In office

Please sign the application at the end.  CA SIP IS REQUIRED

This position can be remote. If you live in the Fresno area it will be in the office or Hybrid.

 

POSITION SUMMARY:  Under general 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 150 to 180 workers’ compensation files, including complex claims.*
  • Initiates and conducts claims investigation in a timely manner.*
  • Determines compensability of claims and administer 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 as appropriate.  Monitors legal aspects.*
  • Communicates with claimants, providers and vendors regarding claims issues.*
  • Computes and set reserves within Company guidelines.  Limits are less than those allowed for Claims Examiner III, but larger than those for Claims Examiner I.*
  • Settles and/or finalize all claims and obtains authority as designated.*
  • Maintains diary system for case review and document 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.*
  • Participates in file reviews, as needed.
  • Other duties as assigned.

 

*Essential job function.

 

 

Qualifications

QUALIFICATIONS REQUIRED:

 

Education/Experience:  Bachelor’s degree in related field (preferred); five (5) years related experience; or equivalent combination of education and experience.   Must be familiar with 4850.

 

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: 

  • Certification and/or license as required by State regulation.

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

  • Medical, Dental, Vision, Disability and Life insurance
  • 401(k) plan
  • Paid Holidays
  • Paid Time off

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.    Exerting up to 10 pounds frequently

c.    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:

a.    Exerting up to 50 pounds of force occasionally

b.    Exerting up to 20 pounds of force frequently

c.    Exerting up to 10 pounds of force constantly to move objects

 

          Heavy work:

a.    Exerting up to 100 pounds of force occasionally

b.    Exerting up to 50 pounds of force frequently

c.    Exerting up to 20 pounds of force constantly to move objects

 

          Very heavy work:

a.    Exerting in excess of 100 pounds of force occasionally

b.    Exerting in excess of 50 pounds of force constantly to move objects

c.    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

 

2.  PHYSICAL EFFORT (cont.)

    FREQUENCY

 

c.    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.

 

 X    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.

 

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

 

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

 

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

 

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

 

 X    Standing:       Particularly for sustained periods of time.

 

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

 

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

 

 X    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.

 

 X    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.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occasionally

 

 

 

Occasionally

 

Occasionally

 

 

 

Occasionally

 

Occasionally

 

Occasionally

 

Occasionally

 

 

Occasionally

 

 

 

 

 

Frequently

 

 

 

 

Frequently

 

 

Occasionally

 

 

 
       

 

 

2.  PHYSICAL EFFORT (cont.)                  

      FREQUENCY

 X    Talking:         Expressing or exchanging ideas by means of the spoken word.  Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

 

 X    Hearing:        Perceiving the nature of sounds with or without correction.  Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts.

 

       Feeling:         Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.

 

 X    Repetitive      Substantial movements (motions) of the wrists, hands,

       Motion:         and/or fingers.

Frequently

 

 

 

Frequently

 

 

 

 

 

 

 

Frequently

 

 

3.  WORKING CONDITIONS

 

Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure. 

 

       WORKING CONDITION

           ENVIRONMENTAL

                     FACTOR

           NATURE/REASON

               OF EXPOSURE

 

                FREQUENCY

Dirt/Dust

 

 

Noise

 

 

Temperature extremes

 

 

Dampness

 

 

Vibrations

 

 

Equipment movement hazard

 

 

Chemicals/solvents

 

 

Electrical shock

 

 

Significant work pace/pressure

 

 

Odors/Fumes

 

 

Other (specify):                              

 

                                                         

 

 
       

 

 

 

 

Required profile

Experience

Level of experience: Senior (5-10 years)
Industry :
Insurance
Spoken language(s):
English
Check out the description to know which languages are mandatory.

Hard Skills

State LawsIn-LicensingMedical TerminologyClaims ProcessingRegulatory Compliance

Other Skills

  • Problem Solving
  • Verbal Communication Skills
  • Microsoft Excel
  • Analytical Skills
  • Social Skills
  • Time Management
Are you interested?

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