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Job Description

Req#: 336445

Job Details

Level: Experienced

Job Location: Sacramento - Rancho Cordova, CA

Position Type: Full Time

Education Level: High School Diploma or GED

Salary Range: $65,000.00 - $75,000.00 Salary/year

Travel Percentage: None

Job Shift: Day

Job Category: Insurance

Claims Examiner I _ Medical Only

POSITION SUMMARY: At the direction of the Claims Supervisor (or designated CE III Mentor) manages all aspects of Medical Only claims from inception to conclusion within established authority and guidelines. Once proficiency is established, additional responsibilities will include handling minor lost time and future medical claims.

This position requires considerable interaction with clients, claimants, Providers, Claims Examiners, and other TRISTAR staff. Therefore consistently being at work in the office or home office location as applicable, in a timely manner, is inherently required of this position.

DUTIES AND RESPONSIBILITIES:

Effectively manages a caseload of 150 to 200 workers’ compensation files.*
Initiates and conducts claims investigation in a timely manner.*
Medical only, indemnity transition.
Determines compensability of claims and administers benefits, based upon state laws and rules and in accordance with established Company guidelines.*
Manages medical treatment and medical billing, authorizing as appropriate, with requests for surgical treatment to be referred to supervisor prior to authorizing. *
Communicates with claimants, providers and vendors regarding claims issues.*
Computes and set reserves within Company guidelines, up to $*****. *
Finalizes all claims and obtains authority as designated.*
Maintains diary system for case review and document file to reflect the status of 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 designated loss control staff when appropriate.*
Adheres to all Company policies and procedures.*
Participates in file reviews, as needed.
Other duties as assigned include assisting as a claims assistant.

*Essential job function.

EQUIPMENT OPERATED/USED: Computer, fax machine, copier, printer, and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire

Other duties as assigned

Qualifications

QUALIFICATIONS REQUIRED:

Education/Experience : Bachelor’s degree in a related field (preferred); and one (1) year of 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 the ability to convey technical details to claimants, clients, and staff.
Ability to interact with persons at all levels in the business environment.
Proficient in Word and Excel (preferred).

Other Qualifications :

Certification and/or or license as required by State regulation.

Here is some of the benefits you can enjoy in this role

Medical, Dental & Vision Insurance
Life & Disability insurance
401 (k) plan
Paid time off
Paid holidays
Referral bonus

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

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORT

a. Reasoning development::

Follow one- or two-step instructions; routine, repetitive tasks.

Carry out detailed but uninvolved written or verbal instructions; deal with a few concrete

variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

X Solve practical problems; various variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of intellectual and practical problems; comprehend most obscure concepts.

b. Mathematical development:

Simple addition and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole numbers.

X arithmetic calculations involving fractions, decimals, and percentages.

Arithmetic, algebraic, and geometric calculations.

Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

c. Language development:

Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

X Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

2. PHYSICAL EFFORT

a. 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. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

X Light work:

a. Exerting up to 20 pounds of force occasionally

b. Exerting up to 10 pounds frequently

c. Exerting a negligible amount of force constantly to move objects

(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

Medium work:

a. Exerting up to 50 pounds of force occasionally

b. Exerting up to 20 pounds of force frequently

c. Exerting up to 10 pounds of force constantly to move objects

Heavy work:

a. Exerting up to 100 pounds of force occasionally

b. Exerting up to 50 pounds of force frequently

c. Exerting up to 20 pounds of force constantly to move objects

Very heavy work:

a. Exerting in excess of 100 pounds of force occasionally

b. Exerting in excess of 50 pounds of force constantly to move objects

c. Exerting in excess of 20 pounds of force constantly to move objects

Visual requirements necessary to perform the job:

Far vision: clarity of vision at 20 feet or more

X Near vision: clarity of vision at 20 inches or less

X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet

Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are

Color vision: ability to identify and distinguish colors

Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point

2. PHYSICAL EFFORT (cont.)

FREQUENCY

c. 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. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.

Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

X Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.

X Kneeling: Bending legs at knee to come to a rest on knee or knees.

X Crouching: Bending the body downward and forward by bending legs and spine.

Crawling: Moving about on hands and knees or hands and feet.

X Reaching: Extending hand(s) and arm(s) in any direction.

X Standing: Particularly for sustained periods of time.

X Walking: Moving about on foot to accomplish tasks, particularly for long distances.

X Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.

X Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.

Foot

Motion: Using feet to push pedals.

X Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.

X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.

X Grasping: Applying pressure to an object with the fingers and palm.

Occasionally

Frequently

Occasionally

2. PHYSICAL EFFORT (cont.)	FREQUENCY
X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly. X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication, and to make fine discriminations in sound, such as when making find adjustments on machined parts. Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips. X Repetitive Substantial movements (motions) of the wrists, hands, Motion: and/or fingers.	Frequently Frequently Frequently
3. WORKING CONDITIONS Disagreeable job conditions to which the employee may be exposed and the frequency (e.g., continually, frequently, or occasionally) of this exposure.
WORKING CONDITION ENVIRONMENTAL FACTOR	NATURE/REASON OF EXPOSURE	FREQUENCY
Dirt/Dust
Noise
Temperature extremes
Dampness
Vibrations
Equipment movement hazard
Chemicals/solvents
Electrical shock
Significant work pace/pressure
Odors/Fumes
Other (specify):