Workers Compensation Claims Examiner III

TRISTAR Insurance Group; Houston, Northern (TX, KY); Hybrid; USD 52,000 - 82,000; Full time

Benefits offered by this job

Medical, Dental & Vision Insurance

Life & Disability Insurance

401(k) plan

Paid time off

Paid holidays

Job summary

TRISTAR Insurance Group seeks an experienced Claims Examiner to manage a large workers’ compensation caseload and handle complex claims in Houston. You will investigate, determine compensability, and manage medical treatment and billing under state law and Company guidelines.

You will communicate with claimants, providers, and vendors, maintaining diaries and improving efficiency, with a strong emphasis on accuracy and timely resolution. A strong client service mindset is essential.

Qualifications

• High School Diploma or GED is required; a related Bachelor's degree is preferred.
• 5+ years of workers' compensation claims experience or equivalent.
• Knowledge of statutory regulations and medical terminology.
• Excellent written and verbal communication; ability to explain complex details clearly.
• Proficient in Word and Excel.

Responsibilities

• Manage a caseload of 110–150 workers’ compensation files, including complex claims.
• Initiate and conduct investigations in a timely manner.
• Determine compensability and administer benefits per state law and guidelines.
• Manage medical treatment and billing; authorize as appropriate.
• Communicate with claimants, providers, and vendors on claims issues.

Skills

Regulations knowledge

Medical terminology

Analytical skills

Communication skills

Claims handling

Education

High School Diploma or GED

Bachelor’s degree (preferred)

Tools

Microsoft Word

Microsoft Excel

Job description

Houston Office - Houston, TXHigh School Diploma or GED**POSITION SUMMARY:** 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, 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.**DUTIES AND RESPONSIBILITIES:*** Effectively manages a caseload of 110 to 150 workers’ compensation files, including very complex claims.\** 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.\** Communicates with claimants, providers and vendors regarding claims issues.\** Computes and set reserves within Company guidelines.* 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 attireEducation/Experience: High School Diploma or GED required. 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).Other Qualifications: * Medical, Dental & Vision Insurance* Life & Disability Insurance* 401(k) plan* Paid time off* Paid holidays.Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements] **MENTAL AND PHYSICAL REQUIREMENTS** | | | 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. 1. 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 | | | X Walking: Moving about on foot to accomplish tasks, particularly for long distances. X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts.| Personal information categories | A name, alias, address, telephone number, email address, government-issued identification numbers, education, employment, employment history, date of birth, phone number, credential or license information | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Professional or employment-related information | Current or past job history or performance evaluations, credential or license information, compensation requirements, job application materials | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Education information subject to the Family Educational Rights and Privacy Act | Education records directly related to a student maintained by an educational institution or party acting on its behalf, such as grades, transcripts, class lists, or student disciplinary records. | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Personal information categories | A name, alias, address, telephone number, email address, government-issued identification numbers, education, employment, employment history, date of birth, phone number, credential or license information | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Professional or employment-related information | Current or past job history or performance evaluations, credential or license information, compensation requirements, job application materials | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Education information subject to the Family Educational Rights and Privacy Act | Education records directly related to a student maintained by an educational institution or party acting on its behalf, such as grades, transcripts, class lists, or student disciplinary records. | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Personal information categories | A name, alias, address, telephone number, email address, government-issued identification numbers, education, employment, employment history, date of birth, phone number, credential or license information | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Professional or employment-related information | Current or past job history or performance evaluations, credential or license information, compensation requirements, job application materials | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None || Education information subject to the Family Educational Rights and Privacy Act | Education records directly related to a student maintained by an educational institution or party acting on its behalf, such as grades, transcripts, class lists, or student disciplinary records. | Yes | Business Partners, TRISTAR Vendors, Government Agencies, Legal Counsel | None |