About This Role
This Claims Examiner I position involves managing all aspects of medical-only claims from start to finish, working within established guidelines and authority. The role requires significant interaction with clients and claimants over the phone, as well as with management and other staff in the office, making consistent and timely office presence essential.
Responsibilities
- Effectively manage a caseload of 150 to 180 workers’ compensation files
- Initiate and conduct claims investigations in a timely manner
- Determine compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines
- Manage medical treatment and medical billing, authorizing as appropriate
- Communicate with claimants, providers, and vendors regarding claims issues
- Compute and set reserves within Company guidelines
- Maintain diary system for case review and document file to reflect the status of and work being performed on the file
- Communicate appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns
- Involve TRISTAR loss control staff when appropriate
- Adhere to all Company policies and procedures
- Participate in file reviews, as needed
- Perform other duties as assigned
Requirements
- Minimum of one year of related experience; or equivalent combination of education and experience
- 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
Nice to have:
- Proficient in Word and Excel
Benefits
- Medical, Dental, Vision Insurance
- Life and Disability Insurance
- 401(k) Plan
- Paid Holidays
- Paid Time Off
- Referral bonus
Important Details
- Equipment operated/used: Computer, telephone, 10-key, fax machine, printers and other basic office equipment
Physical Requirements
- Mental effort: Solve practical problems; variety of variables with limited standardization; interpret instructions
- Mathematical development: Arithmetic calculations involving fractions, decimals, and percentages
- Language development: Transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants
