Workers Compensation Claims Examiner III

Tristar Insurance; Philadelphia (Philadelphia County); On-site; USD 85,000 - 95,000; Full time

Job summary

Tristar Insurance is seeking an experienced Claims Adjuster to manage all aspects of indemnity claims handling. This role is based in Philadelphia and will require you to effectively manage a caseload of 125 to 150 complex claims while communicating regularly with clients and other stakeholders.

The ideal candidate will have a bachelor’s degree, three years of experience, and strong analytical and communication skills. This position offers a full-time role with a salary range of $85,000 to $95,000.

Qualifications

• Bachelor’s degree in a related field or equivalent experience.
• Three or more years related experience.
• Must be licensed to handle claims in NY.

Responsibilities

• Effectively manage a caseload of 125 to 150 workers’ compensation files.
• Conduct investigations into claims and determine compensability.
• Manage medical billing and authorizations as needed.
• 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 independently manage complex claims

Proficient in Word and Excel

Education

Bachelor’s degree in related field (preferred)

Job description

Job Details: Level: Experienced | Job Location: Philadelphia Office - Philadelphia, PA 19107 | Position Type: Full Time | Education Level: High School Diploma or GED | Salary Range: $85,000.00 - $95,000.00 | Travel Percentage: None | Job Shift: Day | Job Category: Admin - Clerical

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

• Adjuster will work hybrid
• Effectively manages a caseload of 125 to 150 workers’ compensation files, including very complex claims.
• Jurisdiction is NY.* (experience handling NJ claims a plus)
• 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.
• Refers cases to outside defense counsel. Directs and manages as appropriate.
• Communicates with claimants, providers and vendors regarding claims issues.
• Computes and sets reserves within Company guidelines. Limits are larger than those allowed for Claims Examiner I and Claims Examiner II.
• Settles and/or finalize 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.
• Involves TRISTAR loss control staff when appropriate.
• Adheres to all Company policies and procedures.
• Conducts file reviews independently.
• Other duties as assigned.

Equipment Operated/Used

Computer, fax machine, copier, printer, and other office equipment.

Special Equipment or Clothing

Appropriate business casual office attire.

Qualifications

• Education/Experience: Bachelor’s degree in related field (preferred); three (3) 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).
  • Must be licensed to handle claims in NY.

Mental and Physical Requirements

See separate attachment for a copy of checklist of mental and physical requirements.Detailed requirements:1. MENTAL EFFORTa. Reasoning development: Follow one- or two-step instructions; routine, repetitive task.b. Mathematical development: Arithmetic calculations involving fractions, decimals, and percentages.c. Language development: Ability to compose original correspondence, follow technical manuals, and have increased contact with people.2. PHYSICAL EFFORTa. 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.Light work: Exerting up to 20 pounds of force occasionally; Exerting up to 10 pounds frequently; Exerting a negligible amount of force constantly to move objects.Medium work: Exerting up to 50 pounds of force occasionally; Exerting up to 20 pounds of force frequently; Exerting up to 10 pounds of force constantly to move objects.Heavy work: Exerting up to 100 pounds of force occasionally; Exerting up to 50 pounds of force frequently; Exerting up to 20 pounds of force constantly to move objects.Very heavy work: Exerting in excess of 100 pounds of force occasionally; Exerting in excess of 50 pounds of force constantly to move objects; Exerting in excess of 20 pounds of force constantly to move objects.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.- Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces.- Stooping: Bending body downward and forward by bending spine at the waist.- Kneeling: Bending legs at knee to come to a rest on knee or knees.- Crouching: Bending the body downward and forward by bending legs and spine.- Crawling: Moving about on hands and knees or hands and feet.- Reaching: Extending hand(s) and arm(s) in any direction.- Standing: Particularly for sustained periods of time.- Walking: Moving about on foot to accomplish tasks, particularly for long distances.- Pushing: Using upper extremities to press against something with steady force in order to thrust forward, downward, or outward.- Pulling: Using upper extremities to extend force in order to drag, haul, or tug objects in a sustained motion.- Foot Motion: Using feet to push pedals.- Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position.- Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm.- Grasping: Applying pressure to an object with the fingers and palm.- Talking: Expressing or exchanging ideas by means of the spoken word.- Hearing: Perceiving the nature of sounds with or without correction.- Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.- Repetitive: Substantial movements (motions) of the wrists, hands, and/or fingers.3. WORKING CONDITIONS- Dirt/Dust- Noise- Temperature extremes- Dampness- Vibrations- Equipment movement hazard- Chemicals/solvents- Electrical shock- Significant work pace/pressure- Odors/Fumes- Other (specify):

Legal Disclaimer

TRISTAR complies with all federal, state, and local Equal Employment Opportunity laws and does not discriminate on the basis of protected characteristics.