- Effectively manages a caseload of 150 to 180 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.*
- Refers cases to outside defense counsel. Directs and manages as appropriate.*
- Communicates with claimants, providers and vendors regarding claims issues.*
- Computes and set reserves within Company guidelines. Limits are larger than those allowed for Claims Examiner I and Claims Examiner II.*
- Settles and/or finalize all claims and obtains authority as designated.*
- 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.
- 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).
- SIP Certifications required
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Imperial Health Plan of California, Inc. Pasadena, United StatesJOB SUMMARY: Is responsible for adjudicating complex claims which include high dollar claims. Responsible for accurate manual/auto pricing of claims. Identify provider billing issues that impact claims processing. Works closely with the Supervisor to identify any reporting or tra ...
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Innovative Management Systems Incorporated Bassett, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
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Innovative Management Systems Incorporated CITY OF INDUSTRY, CA, US, United States Full time:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
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Innovative Management Systems Incorporated Bassett, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
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1 day ago
Innovative Management Systems Incorporated Bassett, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
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Innovative Management Systems Incorporated Bassett, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
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Innovative Management Systems Incorporated La Puente, United States: We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, an ...
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Claims Examiner II/III
1 day ago
Innovative Management Systems Incorporated CITY OF INDUSTRY, CA, US, United States:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organization, managed service organization, IPA, and ...
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Innovative Management Systems Incorporated La Puente, United StatesJob Description · Job DescriptionDescription:We are looking for a Claims Examiner II/III, depending on their knowledge and experience. This position is not an entry level position and will need to fully understand Medicare claims processing specifically in a managed care organiza ...
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Department of Financial Protection and Innovation Los Angeles, United States**About the DFPI** · The Department of Financial Protection and Innovation (DFPI) is California's financial regulator, working to protect consumers by examining and licensing financial activities and taking action against unfair, deceptive, or abusive practices. We oversee state- ...
Workers Compensation Claims Examiner III - Signal Hill, United States - Tristar Insurance Services LLC
Description
Job DetailsLevel
Experienced
Job Location
Signal Hill Office - Signal Hill, CA
Remote Type
Fully Remote
Position Type
Full Time
Education Level
High School Diploma or GED
Salary Range
$85, $95,000.00 Salary/year
Travel Percentage
None
Job Shift
Day
Job Category
Insurance
Workers Compensation Claims Examiner III (Remote)
Please complete all of the questions, information and sign your application at the end.
This position requires the employee to be bilingual English/ Spanish. Must have a CA SIP and reside in California.
POSITION SUMMARY: Under minimal 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:
Qualifications
Education/Experience: 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: