Workers Compensation Claims Examiner III (Hybrid)

Tristar Insurance; Concord (CA); On-site; USD 90,000 - 100,000; Full time

Job summary

Tristar Insurance is seeking an Insurance Claims Adjuster to join our Concord, CA office. The candidate will investigate and settle complex Workers’ Compensation claims, ensuring compliance with policies and regulations. A minimum of three years' experience is required, with strong analytical and communication skills essential for success in this role.

The position provides opportunities for career development and offers a supportive work environment within our dynamic team.

Qualifications

• Three to five years of Workers’ Compensation Claims administration experience required.
• Experience with complex and high exposure claims is strongly preferred.
• Ability to work in a fast-paced, high-stress environment.

Responsibilities

• Investigates and settles moderately complex to complex claims.
• Analyzes claim exposure and determines proper action plan.
• Coordinates medical treatment for injured workers.

Skills

Analytical skills

Communication skills

Negotiation skills

Bilingual Spanish

Education

High School Diploma or GED

Bachelor’s degree in related field

Tools

Microsoft Office

Claims administration applications

Job description

Job Details

Level: Experienced

Job Location: Concord Office – Concord, CA 94520

Position Type: Full Time

Education Level: High School Diploma or GED

Salary Range: $90,000.00 - $100,000.00 per year

Travel Percentage: Negligible

Job Shift: Day

Job Category: Insurance

Job Summary

Investigates, evaluates, disposes and settles moderately complex to complex/high exposure claims. Includes the investigation, evaluation and determination of coverage, compensability and responsibility and the setting of proper reserves.

Duties and Responsibilities

• Processes moderately complex to complex or high exposure claims consistent with clients’ and corporate policies, procedures and “Best Practices” and in accordance with any statutory, regulatory and ethics requirements.
• Independently analyzes claim exposure, determines a proper plan of action to appropriately mitigate and settle/close the claim working within established level of authority.
• Interacts with injured workers, client contacts and attending Physician(s) to ensure awareness and understanding of the Workers’ Compensation process, requirements and entitlements.
• Interacts with disability and leave examiners for coordination of non-occupational benefits.
• Prepares and issues notices in accordance with mandated requirements and regular reviews and stays abreast of applicable laws, rules and regulations that may impact claim processing.
• Establishes and maintains proper reserving throughout the life of the claim.
• Identify subrogation potential and pursue the process for reimbursement.
• Complies with carrier excess reporting and threshold requirements.
• Coordinates medical treatment for injured workers and provides information to treating physicians(s) regarding the employee’s medical history, health issues and job requirements.
• Fully understands Medicare reporting requirements as they relate to a Workers’ Compensation claim.
• Facilitates early RTW through temporary, transitional, alternate, or modified work.
• Manages all medical aspects of a claim file with a focus on RTW and end of treatment.
• Refers appropriate files for task management assignments to approved vendors for medical management, special investigative needs, conditional payments, etc. up to assigned authority.
• Monitors status and quality of work performed.
• Serves as a liaison between medical providers, employees, legal professionals, clients and vendors.
• Independently manages claims in litigation with regular and consistent communication with defense counsel to make recommendations and develop strategy.
• Enter and maintain accurate information in the claims management computer system.
• Clearly communicates concise action plans and present plans for moving the claim to resolution.
• Meets with clients to discuss on-going claims or review open claim inventory.
• Effectively controls expenses on all Workers’ Compensation claims.
• Mentors first level WC Examiners.
• All other duties as assigned.

Equipment Operated/Used

• Computer
• Fax machine
• Copier
• Printer
• Other office equipment

Special Equipment or Clothing

Appropriate office attire.

Qualifications

Education: High School Diploma or GED required; Bachelor’s degree in related field (strongly preferred) or equivalent combination of education and experience.

Experience: Three (3) to five (5) years of Workers’ Compensation Claims administration experience required working with self‑insured and/or insured claims.

Preferred Skills

• Demonstrated experience working with complex, high exposure and litigated WC claims.
• Appropriately licensed and/or certified in all States in which claims are handled. Multi‑Jurisdiction experience is a (+).
• Bilingual Spanish is a (+).
• Able to work in a fast paced, high stress, changing environment.
• Strong analytical, critical thinking and problem‑solving skills are required.
• Effective verbal and written communication skills required.
• Excellent planning, organizing and negotiation skills required.
• Attention to detail.
• Negotiation and interpretive skills necessary.
• Demonstrated knowledge of established claims strategy and mitigation techniques.
• Establishes and maintains effective working relationships with those contacted in the course of work.
• Proficiency with computers and technology – working knowledge of Microsoft Office application suite (Word, Excel, etc.) and familiarity and experience using standard claims administration applications.
• Good interpersonal skills with an ability to work within a team environment.
• Able to effectively handle multiple priorities simultaneously.
• Works independently.

Mental and Physical Requirements

Vision: Near, Mid‑range, Depth perception, Color vision, Field of vision.

Physical effort categories – Light, Medium, Heavy, Very heavy with examples of necessary force and movements (exerting up to 10‑100 pounds, climbing, stooping, kneeling, crouching, reaching, standing, walking, pushing, pulling, lifting). Frequency of activities: occasionally, frequently, sustain.

Working Conditions

Potential exposure to: dirt/dust, noise, temperature extremes, dampness, vibrations, equipment movement hazard, chemicals/solvents, electrical shock, significant work pace/pressure, odors/fumes.