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TRISTAR Insurance Group is a national third-party administrator serving employers, insurers, and public entities with insurance administration and risk management services. The company supports property and casualty programs, workers’ compensation, general and auto liability, managed care, absence and disability management, employee group benefits administration, and workplace safety. Its managed care capabilities include bill review, case management, utilization review, nurse triage, and pharmacy benefit management. TRISTAR combines technology-enabled operations with tailored service to help clients manage risk across complex insurance and employee benefit needs.
Workers Compensation Claims Examiner I - Medical Only (Hybrid)
TRISTAR Insurance Group seeks a hybrid Workers Compensation Claims Examiner I to manage medical-only claims from investigation through resolution. The role covers compensability, treatment and billing coordination, reserves, documentation, and communication with claim stakeholders.
Description
- Manage medical-only workers compensation claims from intake through resolution, keeping total exposure within $10,000 and delegated authority limits
- Open and complete claim investigations promptly
- Assess compensability under applicable state laws and company standards
- Coordinate and oversee medical care and related billing
- Communicate with claimants, employers, providers, vendors, clients, and TRISTAR personnel
- Calculate, set, and revise reserves according to delegated authority and company standards
- Track claims for lost time, potential indemnity exposure, rising medical costs, litigation, and other material changes
- Escalate claims above $10,000 or outside the medical-only scope to a supervisor
- Maintain the claim diary and complete, accurate file records
- Share injury patterns and workplace safety concerns with clients
- Take part in file reviews and complete other assigned responsibilities
Requirements
- High school diploma or GED
- One to three years of relevant work experience
- Working knowledge of workers compensation laws, statutory obligations, and applicable medical terminology
- Ability to investigate and administer medical-only claims within delegated authority and established procedures
- Analytical ability to assess claim facts, medical records, and billing information
- Judgment to identify increasing exposure or complexity and obtain supervisory direction promptly
- Strong organization skills, including diary maintenance, task prioritization, and deadline management
- Clear and effective written and verbal communication
- Professional ability to work with people across all levels of a business
- Microsoft Word and Excel proficiency preferred
- State-required certification or license
- Ability to perform sedentary work and satisfy the role's mental, visual, and physical demands
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