Workers' compensation claims examiner i / medical only

Job Details:

• Job Location: Dallas - Irving, TX
• Position Type: Full Time
• Education Level: High School Diploma or GED
• Salary Range: $24.03 - $26.44 Hourly
• Travel Percentage: None
• Job Shift: Day
• Job Category: Admin - Clerical
• This is an in-office position, with a possible hybrid schedule after 90-days of training

POSITION SUMMARY: Under close to moderate supervision, manages workers’ compensation medical-only claims from inception through resolution, with total claim exposure not exceeding $10,000 and within assigned authority limits and established company and client guidelines. Coordinates medical treatment, reviews medical billing, maintains accurate claim documentation, and communicates with clients, claimants, employers, medical providers, and TRISTAR staff. Identifies and promptly escalates claims involving potential indemnity benefits, increased exposure, disputed issues, or complexity beyond the medical-only scope.

DUTIES AND RESPONSIBILITIES:

• Manages medical-only workers’ compensation claims with total exposure up to $10,000, within assigned authority limits and under close to moderate supervision.
• Initiates and conducts timely investigations to gather information needed to evaluate claims.
• Determines compensability of medical-only claims in accordance with applicable state laws and company guidelines, seeking supervisory guidance on disputed or unusual matters.
• Coordinates and monitors medical treatment and medical billing, providing authorization within assigned authority.
• Communicates professionally with claimants, employers, medical providers, and vendors regarding claim status, treatment, billing, and other claims issues.
• Calculates, establishes, and adjusts reserves within assigned authority and company guidelines.
• Monitors claims for lost time, potential indemnity benefits, increased medical exposure, litigation, or other developments requiring supervisory review or reassignment.
• Promptly refers claims exceeding $10,000 in total exposure or the medical-only scope to the supervisor for review and appropriate reassignment.
• Maintains a diary system for timely case review and documents claim files to accurately reflect claim status and handling activities.
• Promptly communicates relevant information to clients, including injury trends and safety concerns.
• Adheres to all company policies, procedures, and applicable client claims handling instructions.
• Participates in file reviews as needed.

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); and one (1) to three (3) years related experience; or equivalent combination of education and experience.
• Knowledge, Skills and Abilities: Working knowledge of applicable workers’ compensation laws, statutory requirements, and medical terminology relevant to medical-only claims. Ability to investigate and manage medical-only claims within assigned authority and established guidelines. Analytical skills to evaluate claim information, medical documentation, and billing. Ability to recognize changes in claim exposure or complexity and seek supervisory guidance promptly. Strong organizational skills and the ability to maintain a diary system, prioritize tasks, and meet deadlines. Effective written and verbal communication skills, including the ability to explain claims information clearly to claimants, clients, and staff. Ability to interact professionally with individuals at all levels of the business environment. Proficiency in Microsoft Word and Excel preferred.
• Other Qualifications: Certification and/or license as required by State regulation. Requires an active Texas workers' compensation adjuster's license.

Mental and Physical Requirements:

[see separate attachment for a copy of checklist of mental and physical requirements]