Workers Compensation Claims Examiner I Medical Only

POSITION SUMMARY: Under general supervision manages all aspects of indemnity claims handling from inception to conclusion within established authority and guidelines.

This position requires considerable interaction with clients claimants on the phone and with management other Claims Examiners and other TRISTAR staff in the office; therefore consistently being at work in the office in a timely manner is inherently required of this position.

DUTIES AND RESPONSIBILITIES:

• Effectively manages a caseload of 150 to 180 workers compensation files including complex claims.*
• Initiates and conducts claims 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.*
• Refers cases to outside defense counsel as appropriate. Monitors legal aspects.*
• Communicates with claimants providers and vendors regarding claims issues.*
• Computes and set reserves within Company guidelines. Limits are less than those allowed for Claims Examiner III but larger than those for Claims Examiner I.*
• Settles and/or finalize all claims and obtains authority as designated.*
• Maintains diary system for case review and document 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.*
• Involves TRISTAR loss control staff when appropriate.*
• Adheres to all Company policies and procedures.*
• Participates in file reviews as needed.
• Other duties as assigned.

*Essential job function.

EQUIPMENT OPERATED/USED: Computer 10key fax machine copier printer and other office equipment.

SPECIAL EQUIPMENT OR CLOTHING: Appropriate office attire.

QUALIFICATIONS REQUIRED:

Education/Experience: Bachelors degree in related field (preferred); and one 1 to five 5 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:

• Certification and/or or license as required by State regulation. Must have a Texas Adjusters license.

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

MENTAL AND PHYSICAL REQUIREMENTS

1. MENTAL EFFORT

a. Reasoning development::

Follow one or twostep instructions; routine repetitive task.

Carry out detail 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; variety of 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 additional 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

1. 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 Midrange 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

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Occasionally

Frequently

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):