• Claims Examiner II COLA.B- Workers Compensation

    Job Location(s) US-CA-Santa Ana
    Job ID
    # of Openings
    Worker's Compensation/COLA
    Job Type
    Regular Full-Time
  • Overview


    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.




    • Effectively manages a caseload of 150 to 200 workers’ compensation files, including very complex claims.*
    • Initiates and conducts investigation in a timely manner.*
    • Assesses and reviews all facts to determiner compensability and eligibility for Workers’ Compensation benefits (AOE-COE determination)
    • Manages medical treatment and medical billing, authorizing as appropriate.*
    • Directs and reviews all investigatory activity to determine eligibility for benefits and receipt of Workers’ Compensation benefits.
    • Analyze, compute, and process indemnity payments. Audit incoming invoices for accuracy and process payment.
    • Refers cases to outside defense counsel and provide detailed analysis of all legal; medical; and case facts.
    •  Establish claims reserves levels by estimating the cost of each assigned claim; monitor reserves and update amounts as necessary.
    • Communicates with claimants, providers and vendors regarding claims issues. 
    • Prepares and presents detailed case reviews for verbal presentation to clients.
    • Interacts with nurse case managers to proactively manage cases to medical conclusion.
    • Evaluates case facts in psychiatric and stresses cases for eligibility determination and managing such cases to conclusion.
    • 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.*
    • Review and interpret doctor’s reports to ensure that the appropriate American Medical Association (AMA) guidelines have been applied when reporting disability, impairment, and apportionment.
    • Identify subrogation potential and pursue the process of reimbursement.
    • Maintains professional client relationships.
    • Adheres to all Company policies and procedures.*
    • Conducts file reviews as scheduled by the client and management.*
    • Other duties as assigned.
    • Evaluates value of cases for final settlement resolution. Settlement may include a Medicare Set Aside (MSA) or Structure Settlement resolution.


    * Essential job function.





    Education/Experience:  Bachelor’s degree in related field (preferred); three (3) or more 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

    Certifications and/or licenses as required by State regulation.  Self-Insured Certificate


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