WC Claims Examiner III (Hybrid)

Tristar Insurance; Phoenix (AZ); On-site; USD 75,000 - 85,000; Full time

Benefits offered by this job

Medical Insurance

Dental Insurance

Vision Insurance

Life Insurance

Disability Insurance

401(k) Plan

Paid Holidays

Paid Time Off

Referral bonus

Job summary

Tristar Insurance in Phoenix, AZ is seeking an experienced indemnity claims specialist to oversee all aspects of claim handling from inception to resolution. The role manages large workers’ compensation caseloads with emphasis on timely, compliant outcomes.

Responsibilities include initiating investigations, determining compensability, overseeing medical treatment and billing, and coordinating with defense counsel as needed to settle or finalize claims.

Qualifications

• Bachelor’s degree in related field; five (5) or more years related experience; or equivalent combination of education and experience.
• Technical knowledge of statutory regulations and medical terminology.
• Excellent written and verbal communication skills; ability to convey technical details to claimants, clients and staff.

Responsibilities

• Manages an average caseload of 130 workers’ compensation files, including very complex claims.
• Initiates and investigates in a timely manner.
• Determines compensability of claims and administers benefits according to state law and company guidelines.
• Develops and manages claims through action plans toward 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 and directs management as appropriate.
• Manages claim recoveries including deductible and subrogation.

Skills

Indemnity claims handling

Analytical skills

Communication skills

Excel

Self-insured claims

Education

Bachelor’s degree or higher

Tools

10-key

Fax machine

Copier

Printer

Computer

Job description

Job Details: Level: Experienced, Job Location: Phoenix Office - Phoenix, AZ 85014, Position Type: Full Time, Salary Range: $75,000.00 - $85,000.00 Salary/year, Job Shift: Day, Job Category: Insurance

Position Summary

Under minimal supervision, manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.

Duties and Responsibilities

• Effectively manages an average caseload of 130 workers’ compensation files, including very complex claims.*
• Initiates and investigates 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 set reserves within Company 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.*
• Other duties as assigned.*

* Essential job function.

Equipment Operated/Used

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

Special Equipment or Clothing

Appropriate office attire

Qualifications Required

Education/Experience: Bachelor’s degree in related field (preferred); five (5) 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).
• Knowledge of self-insured claims handling (preferred).
• City, County, and/or District claims handling experience (preferred).

Other Qualifications

Certifications and/or licenses 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

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. 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 additional 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 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. X 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 a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met. X Light work: a. Exerting up to 20 pounds of force occasionally b. Exerting up to 10 pounds frequently c. Exerting a negligible amount of force constantly to move objects (If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work). Medium work: a. Exerting up to 50 pounds of force occasionally b. Exerting up to 20 pounds of force frequently c. Exerting up to 10 pounds of force constantly to move objects. Heavy work: a. Exerting up to 100 pounds of force occasionally b. Exerting up to 50 pounds of force frequently c. Exerting up to 20 pounds of force constantly to move objects. Very heavy work: a. Exerting in excess of 100 pounds of force occasionally b. Exerting in excess of 50 pounds of force constantly to move objects c. Exerting in excess of 20 pounds of force constantly to move objects. Visual requirements necessary to perform the job: Far vision: clarity of vision at 20 feet or more X Near vision: clarity of vision at 20 inches or less X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are Color vision: ability to identify and distinguish colors Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point 2. PHYSICAL EFFORT (cont.) FREQUENCY c. Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally): Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion. Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium. X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles. X Kneeling: Bending legs at knee to come to a rest on knee or knees. X Crouching: Bending the body downward and forward by bending legs and spine. Crawling: Moving about on hands and knees or hands and feet. X Reaching: Extending hand(s) and arm(s) in any direction. X Standing: Particularly for sustained periods of time. X Walking: Moving about on foot to accomplish tasks, particularly for long distances. X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward. X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion. Foot Motion: Using feet to push pedals. X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles. X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than the whole hand or arm as in handling. X Grasping: Applying pressure to an object with the fingers and palm. Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Frequently Frequently Frequently Frequently Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasionally Occasional…

Signatures

This job description has been approved by all levels of management:

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____________________