Workers Compensation Claims Examiner -NM

Job Location(s) US-NM-Albuquerque
Job ID
# of Openings
Worker's Compensation
Job Type
Regular Full-Time


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, with management, other Claims Examiners, external business partners and other TRISTAR staff. 



New Mexico license required, multi state experience helpful


Effectively manages an average caseload of 150 workers’ compensation files, including very complex claims.*
Initiates and conducts investigation in a timely manner.*
Determines compensability of claims and administers benefits, based upon state law and in accordance with established Company guidelines.*
Develops and manages claims through well-developed action plans; continues to work the action plan to stay on task and to bring the claim to an appropriate and timely resolution.
Manages medical treatment and medical billing, authorizing as appropriate.*
Calculates and pays benefits due and approves all claim payments.
Refers cases to outside defense counsel.  Directs and manages as appropriate.*
Manages claim recoveries of all types, including deductible and subrogation. 
Communicates with clients, claimants, providers and vendors regarding claims issues.*
Computes and set reserves within Company guidelines.*
Settles and/or finalizes 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.

* Essential job function.



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:

  • 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).
  • Knowledge of self-insured claims handling (preferred).
  • City, County and/or District claims handling experience (preferred).


Other Qualifications


  • Certifications and/or licenses as required by State regulation.


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