Claims Examiner III (Hybrid)

Tristar Insurance; Fresno (CA); On-site; USD 48,216 - 59,236; Part time

Benefits offered by this job

Medical, Dental, Vision Insurance

Life and Disability Insurance

401(k) Plan

Paid Holidays

Paid Time Off

Referral bonus

Job summary

Tristar Insurance is looking for an experienced claims manager for their Fresno Office. This temporary position involves managing all aspects of indemnity claims handling, requiring strong communication, analytical skills, and independent decision-making.

Ideal candidates will have a Bachelor's degree and 1 to 5 years of experience. This role is vital for effective claims handling, ensuring timely communication with claimants and adherence to company guidelines.

Qualifications

• Bachelor’s degree in related field preferred.
• 1 to 5 years related experience required.
• Certification and/or license required by State regulation.

Responsibilities

• Manage a caseload of 150 to 180 workers’ compensation files.
• Conduct claims investigations in a timely manner.
• Determine compensability of claims and administer benefits.
• Manage medical treatment and billing.
• Communicate with claimants and providers regarding claims issues.

Skills

Technical knowledge of statutory regulations and medical terminology

Analytical skills

Excellent written and verbal communication skills

Ability to interact with persons at all levels

Ability to independently manage complex claims

Proficient in Word and Excel

Education

Bachelor’s degree in related field

Tools

Computer

10-key

Fax machine

Copier

Printer

Job description

Job Details

Level: Experienced
Job Location: Fresno Office - Fresno, CA 93727
Position Type: Temporary
Salary Range: $35.00 - $43.00 Hourly
Job Shift: Day
Job Category: Insurance

Position Summary

Under general supervision, manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines. SIP is required for this position. This role requires considerable interaction with clients and claimants on the phone, with management, other Claims Examiners, and other TRISTAR staff in the office; consistently being at work in the office, in a timely manner, is inherently required.

Duties and Responsibilities

• Effectively manages a caseload of 150 to 180 workers’ compensation files, including complex claims.
• Initiates and conducts claims investigation in a timely manner.
• Determines compensability of claims and administers 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 as appropriate and monitors legal aspects.
• Communicates with claimants, providers and vendors regarding claims issues.
• Computes and sets reserves within company guidelines. Limits are less than those allowed for Claims Examiner III, but larger than those for Claims Examiner I.
• Settles and/or finalizes all claims and obtains authority as designated.
• Maintains diary system for case review and document 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.
• Involves TRISTAR loss control staff when appropriate.
• Adheres to all company policies and procedures.
• Participates in file reviews, as needed.
• Other duties as assigned.

Equipment Operated / Used

Computer, 10-key, fax machine, copier, printer and other office equipment.

Special Equipment or Clothing

Appropriate office attire.

Education and Experience

Bachelor’s degree in related field (preferred); and one (1) to five (5) 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

Certification and/or license as required by State regulation.

Benefits

• Medical, Dental, Vision Insurance.
• Life and Disability Insurance.
• 401(k) Plan
• Paid Holidays
• Paid Time Off.
• Referral bonus.

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. 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 additions and subtractions; copying figures, counting, and recording. Add, subtract, multiply, and divide whole numbers. 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. 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: Sedentary work – Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Light work: Exerting up to 20 pounds of force occasionally; 10 pounds frequently; negligible amount of force constantly.

Medium work: Exerting up to 50 pounds of force occasionally; 20 pounds frequently; 10 pounds constantly. Heavy work: Exerting up to 100 pounds of force occasionally; 50 pounds frequently; 20 pounds constantly. Very heavy work: Exerting in excess of 100 pounds occasionally; 50 pounds constantly; 20 pounds constantly.

Visual requirements necessary to perform the job: Far vision – clarity at 20 feet or more. Near vision – clarity at 20 inches or less. Mid-range vision – clarity at distances of more than 20 inches and less than 20 feet. Depth perception – ability to judge distance and space relationships. Color vision – ability to identify and distinguish colors. Field of vision – ability to observe an area up or down or right or left while eyes fixed on a point.

3. WORKING CONDITIONS

Disagreeable job conditions: Dirt / Dust, Noise, Temperature extremes, Dampness, Vibrations, Equipment movement hazard, Chemicals / solvents, Electrical shock, Significant work pace / pressure, Odors / fumes, Other (specify).

Signatures

Human Resources: ___________________
The employee's signature below constitutes the employee's understanding of the mental and physical requirements, essential functions, and duties of the position.
Employee ____________________________ Date ______________________