Claims Examiner III Must have TEXAS workers' compensation license and seeking 5 years experience in lost time work comp claims for TEXAS jurisdiction. POSITION SUMMARY: Under minimal supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.
DUTIES AND RESPONSIBILITIES:- Effectively manages a caseload of 110 to 160 workers’ compensation files, including very complex claims.*
- 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.*
- Communicates with claimants, providers and vendors regarding claims issues.*
- Computes and set reserves within Company guidelines.
- 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.
QUALIFICATIONS REQUIRED:Education/Experience: High School Diploma or GED required. 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).
Other Qualifications:
- Texas Workers Compensation License