TRISTAR Insurance Group · 21 hours ago
WC Claims Examiner III ADR PROGRAM (Temporary)
Fresno Office - Fresno, CA 93727
Full-time
Hybrid
Mid Level
$44/hr - $44/hr
3+ years expTRISTAR Insurance Group is seeking a WC Claims Examiner III for their ADR Program. This role involves investigating, evaluating, disposing, and settling moderately complex to complex/high exposure claims, primarily working with City of Fresno Police Officers and other employees of the Fresno Police Department.
Financial ServicesInsuranceRisk Management
Responsibilities
Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies, procedures and 'Best Practices' and in accordance with any statutory, regulatory and ethics requirements
Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority
Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers’ Compensation process, requirements and entitlements
Interacts with disability and leave examiners’ for coordination of non occupational benefits
Prepares and issues notices in accordance with mandated requirements and regularly reviews and stays abreast of applicable laws, rules and regulations that may impact how claims are processed
Establishes and maintains proper reserving throughout the life of the claim
Identify subrogation potential and pursue the process for reimbursement
Complies with carrier excess reporting and threshold requirements
Coordinates medical treatment for injured workers and provides information to treating physician(s) regarding the employee’s medical history, health issues and job requirements
Fully understands Medicare reporting requirements as they relate to a Workers’ Compensation claim
Facilitates early RTW through temporary, transitional, alternate, or modified work
Manages all medical aspects of a claim file with a focus on RTW and end of treatment
Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority
Monitors status and quality of work performed
Serves as a liaison between medical providers, employees, legal professionals, clients and vendors
Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy
Enters and maintains accurate information in the claims management computer system
Clearly communicates concise action plans and present plans for moving the claim to resolution
Meets with clients to discuss on-going claims or review open claim inventory
Effectively controls expenses on all Workers’ Compensation claims
Mentors first level WC Examiners
All other duties as assigned
Qualification
Required
High School Diploma or GED required
Three (3) to five (5) years of Workers' Compensation Claims administration experience required working with self-insured and/or insured claims
Preferred
Bachelor's degree in related field (strongly preferred) or equivalent combination of education and experience
Demonstrated experience working with complex, high exposure and litigated WC claims
Appropriately licensed and/or certified in all States in which claims are being handled. Multi-Jurisdiction experience is a (+)
Bilingual Spanish is a (+)
Able to work in a fast paced, high stress, changing environment
Strong analytical, critical thinking and problem solving skills required
Effective verbal and written communication skills required
Excellent planning, organizing and negotiation skills required
Attention to detail
Negotiation and interpretive skills necessary
Demonstrated knowledge of established claims strategy and mitigation techniques
Establishes and maintains effective working relationships with those contacted in the course of work
Proficiency with computers and technology – working knowledge of Microsoft Office application suite (MS Word, Excel, etc. and familiarity and experience using standard claims administration applications
Good interpersonal skills with an ability to work within a team environment
Able to effectively handle multiple priorities simultaneously
Works independently
Company
TRISTAR Insurance Group
Tristar Insurance Group provides excellent claims and risk management services to a variety of clients.
501-1000 employees
Funding
Current Stage
Late StageLeadership Team
Denise Cotter
Chief Financial Officer
Linda Naif
Chief Information Officer
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