Workers Compensation Claims Examiner II

## Claims Examiner II

**POSITION SUMMARY:**Under general supervision, manages all aspects of indemnity 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 on time is inherently required of this position.

**DUTIES AND RESPONSIBILITIES:**

• Effectively manages a caseload of 150 or fewer workers’ compensation files, including reasonably complex claims.
• Initiates and investigates promptly\*
• Determines compensability of claims and administers benefits based upon state law and following 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 documents file to reflect the status and work performed on the file.
• Communicates appropriate information promptly to the client to resolve claims efficiently, including any injury trends or other safety-related concerns.
• Adheres to all Company policies and procedures.
• Conducts file reviews as scheduled by the client and management.
• Other duties as assigned.

\* Essential job function.

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

**SPECIAL EQUIPMENT OR CLOTHING:**Appropriate office attire

## Qualifications

**QUALIFICATIONS REQUIRED:**

Education/Experience: High school diploma or GED required; Bachelor’s degree in a related field (preferred); three (3) or more years of 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 conveying 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 fairly complex claims.
• Proficient in Word and Excel (preferred).

Other Qualifications

None

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

• Medical, Dental and Vision insurance
• Life & Disability insurance
• 401(k) plan
• Paid holidays
• Paid time off
• Referral bonus

Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]

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| **MENTAL AND PHYSICAL REQUIREMENTS** |

| **1. MENTAL EFFORT** a. Reasoning development:: Follow one- or two-step instructions; routine, repetitive task. Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables. Follow written, verbal, or diagrammatic instructions; several concrete variables. X Solve practical problems; variety of variables with limited standardization; interpret instructions. Logical or scientific thinking to solve problems; several abstract and concrete variables. Wide range of intellectual and practical problems; comprehend most obscure concepts. |

| b. Mathematical development: Simple additional and subtraction; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. X Arithmetic calculations involving fractions, decimals, and percentages. Arithmetic, algebraic, and geometric calculations. Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination. Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application. |

| c. Language development: Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing. Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction. Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants. X Ability to compose original correspondence, follow technical manuals, and have increased contact with people. Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data. |

| **2. PHYSICAL EFFORT** a. Physical activity required to perform the job: |