Claims Examiner III (Hybrid)

Tristar Insurance•Paradise, NV

6d•$75,000 - $85,000•Hybrid

About The Position

Under minimal 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, management, other Claims Examiners, external business partners, and other TRISTAR staff. This position is a hybrid, temp-to-hire opportunity. Must have a Nevada Adjuster License.

Requirements

Bachelor’s degree in related field (preferred); five (5) or more years 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 the 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).
Certifications and/or licenses as required by State regulation.

Nice To Haves

Knowledge of self-insured claims handling (preferred).
City, County, and/or District claims handling experience (preferred).

Responsibilities

Effectively manages an average caseload of 130 workers’ compensation files, including very complex claims.
Initiates and conducts investigations in a timely manner.
Determines compensability of claims and administers benefits, based upon state law and in accordance with established Company guidelines.
Develops and manages claims through well-developed action plans; continues to work the action plan to stay on task and to bring the claim to an appropriate and timely resolution.
Manages medical treatment and medical billing, authorizing as appropriate.
Calculates and pays benefits due and approves all claim payments.
Refers cases to outside defense counsel. Directs and manages as appropriate.
Manages claim recoveries of all types, including deductible and subrogation.
Communicates with clients, claimants, providers, and vendors regarding claims issues.
Computes and sets reserves within Company guidelines.
Settles and/or finalizes all claims and obtains authority as designated.
Maintains a diary system for case review and documents file to reflect the status 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.
Adheres to all Company policies and procedures.
Conducts file reviews independently.
Other duties as assigned. Essential job function.