• Claims Examiner II

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

    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.

    This position requires determinations of whether claims are delayed, denied, accepted, approvals of vendor bills/invoices and the rating of medical reports to determine the value of potential settlements.





    • Effectively manages a caseload of 150 to 180 workers’ compensation files, including complex claims.* More complex claims are handled by our sensitive examiners.
    • 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 up to $1,000,000.00. Settles and/or finalize all claims and obtains authority as required by County Contract.*
    • 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.*
    • Adheres to all Company policies and procedures.*
    • Participates in file reviews, as needed.
    • Other duties as assigned.


    *Essential job function.




    Education/Experience:  Bachelor’s degree in related field (preferred); equivalent combination of education and experience or two (2) to five (5) years of 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 complex claims.
    • Proficient in Word and Excel (preferred).


    Other Qualifications

    • Completion of the Self Insurance Administrator Competency examination.


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