Workers Compensation Claims Examiner III _ Montana/Boise

TRISTAR Insurance Group; Montana; Remote; USD 75,000 - 90,000; Full time

Job summary

An established industry player is seeking a dedicated claims examiner to oversee complex workers' compensation cases. This role involves managing claims from inception to resolution, requiring strong analytical and communication skills. You will interact with clients, claimants, and external partners, ensuring compliance with regulations and company guidelines. The position offers the flexibility of remote work while being based in Montana. Join a team that values expertise and provides the opportunity to make a significant impact in the insurance sector.

Qualifications

• 5+ years of related experience or equivalent education and experience.
• Technical knowledge of statutory regulations and medical terminology.

Responsibilities

• Manage an average caseload of 130 workers’ compensation files.
• Conduct investigations and determine compensability of claims.
• Communicate with clients and manage claims efficiently.

Skills

Analytical skills

Excellent written and verbal communication skills

Technical knowledge of statutory regulations and medical terminology

Ability to independently manage complex claims

Education

Bachelor’s degree in related field

High School Diploma or GED

Tools

Microsoft Word

Microsoft Excel

Job description

Job Details

Level: Experienced

Job Location: Involuntary Remote - Remote, CA

Position Type: Full Time

Education Level: High School Diploma or GED

Salary Range: $75000.00 - $90000.00 Salary/year

Travel Percentage: None

Job Shift: Day

Job Category: Admin - Clerical

Workers' Compensation CE III_ Montana/Boise

This position is in Montana, but can work remotely from home.

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, with management, other Claims Examiners, external business partners and other TRISTAR staff.

DUTIES AND RESPONSIBILITIES:

• Effectively manages an average caseload of 130 workers’ compensation files, including very complex claims.*
• Initiates and conducts investigation 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

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.
• Must have a Montana Adjuster’s license.
• Multi-Jurisdictional work comp experience a plus as well as Commercial Auto and General Liability.

Mental and Physical Requirements: [see separate attachment for a copy of checklist of mental and physical requirements]