Workers Compensation Claims Examiner III

TeemaGroup; Kapolei (HI); On-site; USD 75,000 - 95,000; Full time

Job summary

A leading claims management firm in Kapolei, HI is seeking a Workers Compensation Claims Examiner III to manage complex indemnity claims and oversee all aspects of claims resolution. Candidates should possess 5+ years of experience in workers’ compensation claims, showcasing the ability to handle litigation and complex claims efficiently. The position requires excellent communication skills and the capability to manage a wide range of stakeholders effectively. Join a dedicated team committed to quality service and client satisfaction.

Qualifications

• Minimum 3+ years of workers’ compensation claims experience for Claims Examiner II.
• Minimum 5+ years of progressive workers’ compensation claims experience for Claims Examiner III.
• Demonstrated experience handling complex and litigated indemnity claims.

Responsibilities

• Manage a full caseload of workers’ compensation claims, including complex indemnity claims.
• Conduct timely and thorough claim investigations.
• Communicate effectively with claimants and medical providers.
• Settle and finalize claims with appropriate authority.

Skills

Claims management

Complex indemnity claims handling

Effective communication

Regulatory compliance

Investigation skills

Education

Bachelor’s degree in a related field

Job description

Job Summary

Workers Compensation Claims Examiner III

TeemaGroup

Full-time

In-Office | Kapolei, HI, United States

POSITION SUMMARY

At the direction of the Claims Supervisor and/or Claims Manager, the Claims Examiner II / III manages all aspects of workers’ compensation indemnity, medical-only, future medical, and litigated claims from inception through resolution, within established authority and company/client guidelines.

This role requires frequent interaction with clients, claimants, medical providers, attorneys, vendors, nurse case managers, vocational case managers, and internal staff.

The level of complexity, litigation exposure, settlement authority, and leadership responsibility will be commensurate with the examiner’s experience and designation (Level II or Level III).

DUTIES AND RESPONSIBILITIES

Core Responsibilities (Applies to Examiner II & III)

• Manage a full caseload of workers’ compensation claims, including complex indemnity claims.
• Initiate, conduct, and document timely and thorough claim investigations.
• Determine compensability and administer benefits in accordance with state laws, rules, and company/client handling instructions.
• Manage medical treatment and medical billing; authorize services as appropriate.
• Communicate effectively with claimants, medical providers, vendors, and clients regarding claim issues.
• Compute and set reserves in accordance with Company and Client guidelines.
• Maintain an organized diary system and document claim files to reflect status, strategy, and action plans.
• Settle and/or finalize claims and obtain appropriate settlement authority.
• Conduct scheduled file reviews and respond to client inquiries.
• Identify injury trends, safety concerns, and other claim-related issues and communicate proactively to clients.
• Adhere to all TRISTAR company policies, procedures, and best practices.
• Utilize office systems and technology efficiently to manage caseload responsibilities.
• Perform other related duties as assigned.

Advanced / Senior Responsibilities (Primarily Examiner III)

• Manage very complex, catastrophic, and litigated indemnity claims from inception to conclusion.
• Refer cases to outside defense counsel and actively participate in litigation strategy, hearings, mediations, and settlements.
• Identify and manage:
  • Subrogation opportunities
  • Apportionment potential
  • Excess reporting criteria and reimbursement
• Prepare and assist with state audits, regulatory reporting, and client-specific reporting requirements.
• Develop and execute proactive claim strategies to drive timely and cost-effective resolution.
• Conduct detailed client file reviews and participate in client meetings as needed.
• Mentor and provide technical guidance to less experienced Claims Examiners.
• Handle multi-jurisdictional workers’ compensation claims as assigned.

Essential job functions.

QUALIFICATIONS REQUIRED

Education & Experience

• Claims Examiner II:
  • Bachelor’s degree in a related field (preferred)
  • Minimum 3+ years of workers’ compensation claims experience, or equivalent combination of education and experience
• Claims Examiner III:
  • Minimum 5+ years of progressive workers’ compensation claims experience
  • Demonstrated experience handling complex and litigated indemnity claims