Key Facts

Remote From:

Oregon (USA) , Pennsylvania (USA)

Full time

Mid-level (2-5 years)

English

Hard Skills

Fraud Investigation Payment Processing Regulatory Compliance Online Communication Stakeholder Communications

Other Skills

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Team Effectiveness
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Non-Verbal Communication
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Time Management
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Detail Oriented

Roles & Responsibilities

Knowledge of Personal Injury Protection (PIP) coverages and determination of coverage issues.
Experience negotiating settlements with attorneys on PIP suits and arbitrations.
Strong documentation and written/verbal communication skills with ability to maintain claim files.
Ability to comply with state regulations and company guidelines, assess fraud indicators, and refer as needed.

Requirements:

Review PIP coverages, investigate loss events, determine coverage decisions and appropriate action.
Negotiate with attorneys to settle PIP suits and arbitrations, and maintain communication while documenting all actions.
Investigate prior losses, order reports as needed, evaluate fraud indicators, and process referrals in compliance with regulations.
Manage medical treatment requests, schedule IMEs when necessary, establish reserves and process claims payments.

TRISTAR Insurance Group

Insurance

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".

Company type: SME

Industry: Insurance

Founded: 2018

Company size: 501 - 1000

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Job description

POSITION SUMMARY: Responsibilities include but are not limited to:

DUTIES AND RESPONSIBILITIES:

Review PIP coverages and/or identify coverage issues and investigate and analyze the loss event, the injury and other relevant information to make a determination as to coverage and course of action.
Negotiate with attorneys to settle PIP Suits and Arbitrations
Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information. Concisely and accurately document all actions taken throughout the course of the claim.
Investigate prior losses and other information on file and orders reports as needed.
Evaluate claims for fraud indicators and potential underwriting issues and process appropriate referrals.
Conduct activities in compliance with state and company regulations and guidelines.
Render final coverage determination within regulatory guidelines: Maintain communication with involved parties during the course of the claim, via written and/or verbal communication, to provide relevant determinations and/or information (Reservation of Right letter, etc.)
Need to recognize prolonged or excessive treatment and promptly schedule an IME with the appropriate medical profession via an approved company vendor.
Generates and sends appropriate forms to insured/claimant for completion.
Processes claims payments.
Completes all necessary forms, logs documents into the system, and routes them to the appropriate parties.
Need to be an effective team player.
Manage all requests for medical treatment, durable medical equipment, PIP Care Paths, medical guidelines and policies, internal and/or external peer reviews and/or IMEs, when required, communicate determinations to appropriate parties within 3 business days.
Request necessary Independent Medical Examinations and render determinations for additional treatment or termination benefits.
Establish adequate medical and non-medical benefits reserves for the life of the claim and adjust reserves, if needed.
Calculate and issue non-medical benefits (wages, essential services, death benefits).

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

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire. Must have a functional office or workspace with reliable direct ethernet internet connection,