Claims Examiner III : WC - TRISTAR Insurance Group, Inc (sacramento/rancho cordova, california)
Posted: Sunday, September 3, 2017 10:10 AM
TRISTAR Insurance Group 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 managed care and benefits administration services were added to our offerings, the organization grew into TRISTAR Insurance Group. Since our merger with Risk Enterprise Management in 2012, we became the largest privately held third party claims administrator. We empower more than 1,000+ professionals in offices throughout the United States, focusing business operations in three divisions: property casualty claims management, benefits administration, and managed care services. We are true to our values of RESPECT, INTEGRITY, TRUST, and EXCELLENCE, making the right choices both financially and ethically. At TRISTAR we strive to create an environment of respect, wherein all of us are encouraged to learn and to grow, to provide exceptional service to our clients and in turn to enjoy the satisfaction that comes from a job well done. We believe that to provide real service, we must contribute something which cannot be bought or measured with money: sincerity and integrity.POSITION SUMMARY: Under supervision, manages all aspects of indemnity and future medical 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 in the office, in a timely manner, is inherently required of this position. This position is a CIGA:dedicated position. CIGA is the California Insurance Guarantee Association which is a quasi:governmental agency which handles claims from insurance carriers that have gone into liquidation. DUTIES AND RESPONSIBILITIES:Effectively manages a caseload of 130 to 150 workersA? compensation files, including very complex claims. All files are CIGA files.*Initiates and conducts investigation in a timely manner.*Determines compensability of claims and administer benefits, based upon state law and in accordance with established Company guidelines.*Manages medical treatment and medical billing, authorizing as appropriate.*Refers cases to outside defense counsel. Directs and manages as appropriate.*Communicates with claimants, providers and vendors regarding claims issues.*Computes and set reserves within Company/Client guidelines.*Settles and/or finalizes 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.*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* Essential job function. EQUIPMENT OPERATED/USED: Computer, 10:key, fax machine, copier, printer, phone, and other office equipment.SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attireA: Other duties as assigned.QUALIFICATIONS REQUIRED:Education/Experience: BachelorA?s degree in related field (preferred); three (3) or more years 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 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:Certifications and/or licenses as required by State regulation.CIGA experience a plus.
• Location: Sacramento
• Post ID: 18495692 sacramento