Workers Compensation Claims Examiner III

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