Claims Examiner I

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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, in a timely manner, is inherently required of this position.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a caseload of 150 to 180 workers’ compensation files.*
• Initiates and conducts claims investigations in a timely manner.*
• Determines compensability of claims and administers benefits, based upon state law and in accordance with established Company guidelines.*
• Manages medical treatment and medical billing, authorizing as appropriate.*
• Communicates with claimants, providers, and vendors regarding claims issues.*
• Computes and sets reserves within Company guidelines.
• 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, 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.

EQUIPMENT OPERATED/USED: Computer, telephone, 10-key, fax machine, printers and other basic office equipment.

QUALIFICATIONS REQUIRED:

Education/Experience:   Minimum of one (1) year of related experience; or equivalent combination of education and experience.