Claims Examiner I (Medical Only/Low Level Lost Time/Future Med)

Job DetailsLevel: ExperiencedJob Location: Sacramento - Rancho Cordova, CA 95670Position Type: Full TimeSalary Range: $28.00 - $30.00 HourlyJob Shift: DayJob Category: InsurancePlease make sure to complete all the questions and navigate to the end of the application to sign it. This position is a hybrid

POSITION SUMMARY:  At the direction of the Claims Supervisor (or designated CE III Mentor) manages all aspects of Medical Only claims from inception to conclusion within established authority and guidelines.  Once proficiency is established, additional responsibilities will include handling minor lost time and future medical claims.

This position requires considerable interaction with clients, claimants, Providers, Claims Examiners, and other TRISTAR staff.  Therefore, consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

 

DUTIES AND RESPONSIBILITIES:


Effectively manages a caseload of 150 to 200 workers’ compensation files.*
Initiates and conducts claims investigation in a timely manner.*
Medical only, indemnity transition.
Determines compensability of claims and administer benefits, based upon state laws and rules and in accordance with established Company guidelines.*
Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing. *
Communicates with claimants, providers and vendors regarding claims issues.*
Computes and set reserves within Company guidelines, up to $*****. *
Finalizes all claims and obtains authority as designated.*
Maintains diary system for case review and document file to reflect the status of 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.*
Involves designated loss control staff when appropriate.*
Adheres to all Company policies and procedures.*
Participates in file reviews, as needed.
Other duties as assigned to include assisting as a claims assistant. 


 

*Essential job function.

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

SPECIAL EQUIPMENT OR CLOTHING:  Appropriate office attire
QualificationsQUALIFICATIONS REQUIRED:

Education/Experience:  Bachelor’s degree in related field (preferred); and one (1) year 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.
Proficient in Word and Excel (preferred).


 

Other Qualifications: 


Certification and/or or license as required by State regulation.


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


Medical, Dental, Vision Insurance.
Life and 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]

 

 





                                     MENTAL AND PHYSICAL REQUIREMENTS




1.  MENTAL EFFORT

 

a.        Reasoning development:

 

           Follow one- or two-step instructions; routine, repetitive task.

 

           Carry out detailed 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 addition 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