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 workers’ compensation files.*
• Initiates and conducts claims investigation in a timely manner.*
• Medical only, indemnity.
• 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, with requests for surgical treatment to be referred to supervisor prior to authorizing. *
• Communicates with claimants, providers and vendors regarding claims issues.*
• Computes and set reserves within Company guidelines, up to $10,000. *
• Finalizes all claims and obtains authority as designated.*
• 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 designated loss control staff when appropriate.*
• 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.