TRISTAR Insurance Group

Claims Examiner III _ (Hybrid)


Pay$90000.00 - $100000.00 / year
LocationRancho Cordova/California
Employment typeOther

What's your preference?

Apply with job updates
  • Job Description

      Req#: 283475

      Job Details

      Level: Experienced
      Job Location: Sacramento - Rancho Cordova, CA
      Position Type: Full Time
      Education Level: High School Diploma or GED
      Salary Range: $90,000.00 - $100,000.00 Salary
      Travel Percentage: None
      Job Shift: Day
      Job Category: Insurance

      Claims Examiner III _ (Hybrid)

      This is a Hybrid position at our Rancho Cordova, CA branch. Please sign the application at the end. SIP required

      POSITION SUMMARY: At the Direction of the Claims Supervisor and/or Manager - manages all aspects of complex and litigated indemnity claims from inception to conclusion within established authority and guidelines.

      This position requires considerable interaction with clients, claimants, Medical providers, Attorneys, vendors, Nurse and Vocational Case Managers and other TRISTAR staff.

      DUTIES AND RESPONSIBILITIES:

      • Effectively manages a caseload of indemnity claim files, including very complex and litigated claims.*
      • Initiates and conducts investigation in a timely manner.*
      • Determines compensability of claims and administer benefits based upon state law and TRISTAR Best Practices for claim handling.*
      • Manages medical treatment and medical billing, authorizing as appropriate.*
      • Refers cases to outside defense counsel and participates in litigated matters.*
      • Communicates with claimants, attorneys, providers and vendors regarding claims issues.*
      • Work in an organized and proactive manner.*
      • Computes and set reserves within Company guidelines.*
      • Settles and/or finalize all claims and obtains authority as designated.*
      • Maintains diary system for case review and documents file to reflect the status and work being performed on the file, including a plan of action.*
      • Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety related concerns.*
      • Conducts file reviews as scheduled by the client and management.*
      • Identify and review claims for Apportionment assignment.*
      • Identify and investigate subrogation potential and pursue recovery.*
      • Identify claim standard criteria for excess reporting and reimbursement.*
      • Assist with State Audit and reporting responses.*
      • Mentors less experienced Examiners
      • Other duties as assigned and including claims management of other jurisdictional workers’ comp claims.
      • Adheres to all TRISTAR company policies and procedures.*

      * Essential job function.

      Qualifications


      Education/Experience : Minimum five (5) or more years related experience; or equivalent combination of education and experience.

      HS diploma required, BS preferred

      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 :

      Licenses as required by Jurisdiction.. SIP required

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

      • Medical, Dental, Vision, Disability & Life insurance.
      • 401(K) plan
      • Paid time off
      • Paid holidays
      • Referral bonus
  • About the company

      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 man...